MINISTRY OF EDUCATION & SCIENCE KYRGYZ REPUBLIC

OSH STATE UNIVERSITY

INTERNATIONAL MEDICAL FACULTY
DEPARTMENT OF «CLINICAL DISCIPLINES 2»

«Disscussed» - «Recommended by » -
in meeting of the department «CD 2» Academic councilor in the department «CD2»
prot.№___from_____2019, Zh. T. Mamytova
head of department, ______________
c.m.s.,assoc.prof.,
M. M. Bugubaeva________

PLAN for PRACTICAL CLASS

TOPIC № 33: Semiotics of violations defined by auscultation (changing tones and murmursof the heart).
TOPIC №34:Measurement technique and assessment of blood pressure in children

DISCIPLINE: “Child diseases (propaedeutic)”

For students, who is studying in direction : (560001) - «General medicine» (GM)
PREPARED BY: Osmonova G.Zh., Mamytova Zh.T., Alimova N.A.

Оsh, 2020.
 TOPIC № 33: Semiotics of violations defined by auscultation (changing tones and murmurs of the heart).
TOPIC №34:Measurement technique and assessment of blood pressure in children

Plan of practical class:

Define the semiotics of disorders defined by auscultation.
2.Tell about pathological auscultative phenomena.
3.Describe the heart murmurs.
4. Tell the difference between functional noise and organic noise
5.Demonstrate the method of measuring blood pressure.
6.Tell the standard blood PRESSURE indicators for each age.

The goal of class:

To study the semiotics of disorders determined by auscultation. To study the value of blood PRESSURE on the hands by age, its ratio with the
indicators of pressure on the legs, the value of the shock volume and the minute volume of blood circulation in the age aspect

Form of Class: subgroup lesson

Type of class: practical class

Equipments used in class: laptop, PPT, a list of test questions,

tonometer, stethoscope,the layout of the child.

Interdisciplinary communication: general anatomy, normal physiology, faculty pediatrics.

Intrasubject communication: Lecture № 13,14

Learning outcomes (LO) and competencies formulated in the process of studying the discipline " Child diseases (propaedeutic)" in the process of
mastering the discipline, the student will achieve the following learning outcomes (LO) and will have the appropriate competencies:

Code of LO in GEP and its
wording
LO-5 - Able to assess
morphofunctional,
physiological conditions and
pathological processes and
Competencies
of GEP
AC-3 - isable and ready to assess
morphological and functional and
physiological states and pathological
processes in the human body, taking into
account their age and sex groups for solving
Code of LO of the discipline (LOd) and its
wording
LOd-5: capable and ready to evaluate
morphofunctional and physiological
physical conditions and is able to
interpret the survey, physical
examination, clinical examination,
Learning outcome of the topic
Able to explain the syndromes
auscultation of the heart:respiratory
arrhythmia, the presence of tone
III, accent and splitting of tone II on
apply research methods for
sick adults and children to
solve professional problems
professional problems; write a medical record of outpatient
and inpatient
sick adult and child and is ready to
conduct pathophysiological analysis
of clinical syndromes;
the pulmonary artery, and is able to
characterize heart murmurs in
children: the frequency of
functional noises, differences
between functional and organic
noises, noises of "small" anomalies
of the heart and blood vessels.

Knows how to correctly measure

blood pressure in children, and
also knows how to tell the normal
blood pressure indicators of each
age.

The synchronous part (ZOOM)

№ Stages Aim of Lecture Actions of Actions of Methods Results of study Equipments Time
teacher students used
1 Organizational Greeting, identifying absentees, Introduction, Writing topic & Ans-Ques pay attention to the lesson Zoom, PPT 5 min
moments organizing attention, discussion of its questions
introduction to new topic, the topic's
checking connecting to the relevance
Zoom conference
2 Survey of material on Generalization of students Asking Selectively Answer the Recalling materials of prerequisites, Ques-answers 5 min
prerequisites knowledge of the materials questions and answer questions contributing to self preparation Application
studied and establish a link with discussing with questions one №1
a new topic. students by one.

3 Motivation for new Enhance students' mental discussion Freely discussion Focusing students on the issues , Zoom 5 min
topic activity, develop critical participate in participating in team discussions,
thinking the discussion, freely express their opinions
the ability to
work in a team
4 Foundation of new determination and analysis shows students looks and Demonstrate A theoretical base of knowledge Zoom , 15 min
topic of the assimilation of the method of repeats,gives the method and skills for use in practical tonometer,
measuring question for of measuring exercises. stethoscop
passed material
blood teacher blood e,the layout
pressure. pressure. of the child.
with the layout
of the child
5 Conclusion of new Definition and analysisof the Question for Writing Question- Independently use the knowledge Question- 10 min
topic and summing material covered, making students question and its Answer gained on the topic, formation of Answer
up changes to its content answer competence

The asynchronous part (all tasks are sent over the Internet)
6 Homework next The main questions of the next Explain how to Writind down Show in PPT Prepare answers for specific Zoom, ppt 10 min
classes topic topic prepare the assignment questions
in notebooks
7 Associate To analyze the education of Send the Send the WhatsApp replenishment Application 20 min
students question for answers №2
students
8 Checking the students Teach students to self-esteem Correction Answer each Questioning Getting information about how Examples & 10 min
and their knowledge other to specific and checking much students understood the new questions
questions asked. each other topic.

Criteria for keeping points:

Attendance Absent-Present 0 points

Notes Absent-present 0-5 points
Active participation in the lesson Discussing the topic, answering for questions, 0-15 points
PPT
MCQ, crosswords, puzzle, clinical cases, According to results of work 10 points
khahoot, practical skills

Application №1
1. .Demonstrate and comment on the technique of performing an external examination of a child with circulatory disease .
2. Show how to detect heart and apical tremors in children. Evaluate the significance of their localization.
3. Remember and write the normal boundaries of the heart in children by age characteristics.
4. Features of auscultation of the heart and blood vessels in children.

Application №2
1. What is a child's blood pressure supposed to be?
2. How do you explain high blood pressure to a child?
3. What does it mean when a child's blood pressure is low?
4. How do you take pediatric blood pressure?
5. What is normal BP for teenage girl?
6. What drink is best for high blood pressure?

Правила измерения артериального давления у детей:

-за 3 часа до измерения не принимать препараты, влияющиена давление, а также продукты.(чай,кофе).
-на 1 час отменить физическую нагрузку.
-В сидячем положении, при необходимости -лежачем.
-аппарат размещается настоле , кровати так,чтобы на одном горизонтальном уровне находились сердца ребенка, рука,нулевой показатель
шкалы и манжетка.
-манжетка полностью освобождается от воздуха,накладывается наплечо на 2см выше локтевой ямки.
-рука ребенка лежит на столе ладонью вверх, мышцы расслаблены
-пальпаторно определяется локализация плечевой артерии в локтевой ямке.
-на место плечевой артерии прикладывается раструб фонендоскопа и нагнетается воздух в манжетку до уровня 40-50 миллиметр .ртутный
.столба и выше тогодавления ,при котором прекратилась пульсация артерии.
-затем медленно снижается давление в манжетке-аускултативно и визуально на ртутном столбике регистрируеся момент появления и
прекращения громких, сильных тонов.

Sphygmomanometers
• There are three different types of sphygmomanometers: mercury, aneroid, and digital.
• Measuring blood pressure by auscultation is considered the gold standard by the Heart, Lung and Blood Institute of the NIH.
 •

Rules for measuring blood pressure in children:

- 3 hours before the measurement, do not take medications that affect blood pressure, as well as products.(tea, coffee).
- cancel physical activity for 1 hour.
-In a sitting position, if necessary-lying down.
-the device is placed on the table, the bed so that the child's heart, hand,zero scale indicator and cuff are on the same horizontal level.
- the cuff is completely released from the air, superimposed on the shoulder 2 cm above the elbow fossa.
-the child's hand is on the table, palm up, the muscles are relaxed
- palpation determines the location of the brachial artery in the ulnar fossa.
-in place of the brachial artery, a phonendoscope socket is applied and air is pumped into the cuff to the level of 40-50 mm. mercury .column
and above the pressure at which the pulsation of the artery stopped.
- then the pressure in the cuff slowly decreases-auscultatively and visually on the mercury column, the moment of appearance and cessation of
loud, strong tones is recorded
.
Изменение тонов сердца.
Ослабление (приглушенных ) тонов сердца.
Ослабление первого тона на верхушке-недостаточности митрального клапана.
Ослабление второго тона над аортой- недостаточности клапанов аорты, стеноз клапанов аорты.

Усиление (акцент) тоновсердца.

Акцент первого тона на верхушке(громкий,хлопающий)-митралным стенозе,
Акцент второго тона над аортой-при артериальной гипертензии,
Акцент второго тона над легочной артерией -стеноз и недостаточность митрального клапана, дефектах межпредсердной и
межжелудочковой перегородки.

Раздвоение (расщепление) тонов сердца.

"Ритм перепела"-характеризуется тремя тонами через короткий промежуток -после второго тона во время диастола определяется третий
тон.(стеноз митрального клапана)
"Ритм галопа"- трехчленный тон.Звучанием он напоминает стук копыт бегущей лощади.(миокардит, пороки сердца, тяжелое инфекционное
заболевание)

Change in heart tones.

The weakening of the (muted ) tones of the heart.
Weakening of the first tone at the top-mitral valve insufficiency.
Weakening of the second tone over the aorta-insufficiency of the aortic valves,stenosis of the aortic valves.

Amplification (Accent) of the heart tone.

Accent of the first tone at the top(loud, clapping) - mitral stenosis,
Accent of the second tone over the aorta-in arterial hypertension,
Second-tone emphasis on the pulmonary artery-stenosis and mitral valve insufficiency, defects of the atrial and inter-ventricular septum.

Split (splitting) of heart tones.

"Quail rhythm" - characterized by three tones in a short interval-after the second tone during diastole, the third tone is determined.(mitral valve
stenosis)
"gallop Rhythm" - three-member tone. It's like the sound of a running horse's hooves.(myocarditis, valvular heart disease, a serious infectious disease)

Heart Murmur
What is a heart murmur?

A heart murmur is the sound of blood flow turbulence in the heart. Some heart murmurs are innocent while others may require referral for additional
medical tests. This video provides an animated view of a heart murmur. While playing the animation, notice the heart valves and blood flow.

Heart Murmur Sounds

This section describes several important attributes of heart murmur sounds.

Timing and Cadence

Our lessons often describe heart murmur timing within a cardiac cycle. Systolic murmurs occur between the first heart sound (S1) and the second heart
sound (S2). Diastolic murmurs occur between S2 and S1. In addition, timing is used to describe when murmurs occur within systole or diastole. For
example, early systolic, mid-systolic or late systolic.
See our courses on systolic and diastolic murmurs for more information including audio recordings, waveforms and animations:

Systolic Murmur

Diastolic Murmur

Duration
Heart murmur duration refers to the portion of systole or diastole that the murmur occupies. Terms used include short and long. Murmurs lasting
throughout systole are referred to as holosystolic or pansystolic.

Pitch
Evaluation of the heart murmur's pitch should be made by classifying the pitch (frequency) as low, medium or high. The stethoscope's bell can be
helpful with low pitched sounds while the diaphragm is used for medium or high pitched sounds.

Shape
A heart murmur can described by the sound's shape. Common classifications include crescendo (increasing intensity), decrescendo (decreasing intensity),
crescendo-decrescendo (increasing then immediate decreasing intensity). Crescendo-decrescendo is also called diamond shaped. Rectangular, also termed
plateau indicates a heart murmur of constant intensity.
Most of our lessons include a waveform with a moving cursor synchronized to the murmur audio. Many users find that the visual depiction of the murmur
sounds is a useful educational tool.
Tonal Quality
Listen for additional aspects of the murmur's sounds. Heart murmurs may have qualities that can be noted as musical, harsh, blowing, booming, sharp or
dull.

Respiration and Patient Position

Respiration or patient position can influence murmur intensity as well as heart sound splitting. These factors will be described within the heart sound lessons.
Generally speaking, murmurs increasing with expiration originate with left side (aortic or mitral) valves, while murmurs increasing in intensity with inspiration
originate with tricuspid or pulmonary valves.
Within each lesson, the author provides an sketch of the patient's position during auscultation, such as supine, left lateral decubitus, squatting or sitting.

Heart Murmur Symptoms

Patients with an abnormal heart murmur may have symptoms or signs or symptoms of the underlying cause of the murmur:

• Chest pain
• Fainting or dizziness
• Bluish color on the fingertips, lips or skin
• Chronic coughing
• Sudden weight gain
• Enlarged neck blood vessels
• Shortness of breath
• Excessive sweating even with minimal or no exertion
• Enlarged liver
• Infants may eat poorly or have
• Infant failure to thrive

.
List of recommended literature
Main literature
1. Propaedeutics childhood diseases childcare: Textbook / Ed. TV Captain. - M.: MEDpress - Inform, 2006 -704 p.
2. Propaedeutics childhood diseases: Textbook / Ed. RR Kildiyarovoy, VI Makarova. - M.: GEOTAR Media, 2012. - 680 p.
3. Propaedeutics childhood diseases: Textbook / Ed. NA Geppe, NS Podchernyaeva - M: GEOTAR Media, 2009. - 464 p.
4 .Mazurin AV Propaedeutics childhood diseases / AV Mazurin, IM Vorontsov - SPb .: Tome, 2001.- 928 p.
Additional literature
5.Poliklinicheskaya pediatrics: medical examination of children: ucheb method. Manual / Under the general editorship. IN Gaymolenko, OA Tihonenko - Chita: IPC
GOU VPO Chelyabinsk State Medical Academy, 2010. - 106 p.
6.Shabalov NP Childhood diseases. - SpetsLit: Saint-Petersburg. - 2007 - 628
7.Kildiyarova RR Pediatrician for every day: a handbook / RR Kildiyarova. - 6 th ed., Rev. and add. - M.: GEOTAR Media, 2009. - 160 p.
8. Children's illnesses. The textbook for doctors - pediatricians / ed. VAShcherbak. - ChitaExpress - publishing, 2008. - 800 p.