Methodical guidance for learning “Metabolic syndrome” for students of 5 –th course icon

Methodical guidance for learning “Metabolic syndrome” for students of 5 –th course




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M. Gorky Donetsk National Medical University


Methodical guidance for learning “Metabolic syndrome” for students of 5 –th course.


Donetsk-2009


Authors:

Turovskaya Т. V., d. of med. s.., professor of Department of internal medicine #3 of M. Gorkiy Donetsk national medical University

Mitchenko E.I., d. of med. s., professor head of Department of dislipidemia NNC “Institute of cardiology by N.D. Stragesko AMN of Ukraine ”, Kiev.


Reviewers:

Parhomenko T.A., assistant professor of Department of internal medicine #2 DonNMU

Basiy R.V., assistant professor of Department of Human Anatomy, Head of the methodical department of DonNMU.


I. Urgency of the topic:


According to the statistic data more then 50 % of the patients of cardiologist have the syndrome of insulin resistance. But in the structure of death of people with diabetes mellitus (DM), cardiac disease are 55 %, and the presence of arterial hypertension in this patient leads to the high risk of cardio-vascular disease and death. This prognosis became worst in the patient with AG or DM cause of presence of dislipidemia or overweight, which registered in more then 50 % of cardiac patients.

More often in the clinical practice there are patient with combination 2 or more factors of risk of development CVD, which leads to enlarge of negative influence and makes prognosis worst..

That’s why we have to give an especial attention to the patient with metabolic syndrome (MS), which characterize of presence of abdominal overweight ( volume of waist for men ≥ 94 cm, for women ≥ 80 cm), and also the presence 2 from 4 listed factors: high level of triglyceride (TG ≥ 1,7 mmol/l); low level of cholesterol lipoproteid of high density (< 1,03 mmol/l in a men and < 1,29 mmol/l in woman) or specific treatment in a patient with dislipidemia; АG (level of systolic pressure ≥ 130 mm.hg.cl., or level of diastolic pressure ≥ 85 mm.hg.cl.) or hypotension treatment in a patient with AG; high level of glucose in blood on an empty stomach ≥ 5,6 mmol/l ( or before diagnosed diabetes mellitus of second type (DM2) типа).

In the end the presence of such a different of clinical syndromes, the specialist of any profile can meet a metabolic syndrome.


^ II. Aim of study


Common aim to know how to make a differential diagnosis of MS and other diseases, which have common clinical symptoms ( arterial hypertension, overweight, hyperglycemia, dislipidemia) to determine tactic of leading of the patient with MS and to argument principal of treating.





^ Principal aims- to know:

For reach the aims of study the basic knowledge-tools are needed:

To find the leading symptoms of MS according the anamnesis of disease.

Выбрать из жалоб, данных анамнеза и объективного исследования сведения, которые отображают наличие МС (факультетская терапия).

To compose an individual net of diagnostic search and to interpret this data with MS. To determine the risk of sickness od DM2 or ICD.


To determine the necessary, volume, and succession of methods of examination: physical, laboratory, and instrumental in a patient with MS (department of ray-therapy, department of physiology and path. Physiology, department of biochemistry, department of propaedeutical therapy, department of faculty therapy).


To make a differential diagnosis of MS with other diseases which characterized by presence of overweight, dislipidemia, arterial hypertension, and hyperglycemia.

To determine syndrome of pathologic of kidneys, cardiac-vascular system, pathology of endocrine organsin a patient with MSand DM (dep. of path. anatomy, dep. of prop. therapy, dep. of endocrine).


To diagnose an urgency situation with MS and DM2 type (hypertension stroke, coma, acute failure of circulation of blood, acute coronary syndrome).

To determine the syndrome of urgency situations of cardio-vascular and endocrine system (dep. of propedeutical anatomy)

Оперделить тактику ведения больного с МС и СД 2 типа.



To use methods of symptomatical and pathogenetic therapy and also recommendation of healthy way of life (dep. of pharmacology, dep. of hygiene of food, dep. of physiotherapy ).





Information which is need to make the basic level of knowledge-tools higher, you can find in next literature isuues :

  1. Human physiology in 3 tomes/ Under red. G. Shmidta, G Tevsa –M. Mir, 1996.- T3.- P. 723-784.

  2. Inner diseases: book in 2 tomes/ Under red A.I. Martinova, N.A. Muhina, V.S. Moiseeva, A.S. Galevich, - M: GEOTAR MED, 2001.- T1.- P. 53-96.

  3. Pathology of diseases of cardio-vascular system/ under red of L. Lilli- M: Binom. Laboratory of science, 2003.- P. 143-150.

  4. Propedeutic of inner disease: 2 publ/ Under red O.V. Sinyachenko, G.A.Ignatenko.- Donetsk: Donechina, 2004.- 544 p.



Tasks for self-control and self control of basic level knowledge- tools


Task 1.

A patient K., a doctor determine the presence of overweight of central type, high level of triglyceride, low level of CLHD, high level of glucose in blood plasma on an empty stomach, arterial hypertension..

What is the symptom between listed is a main in determination of diagnosis of metabolic syndrome, according the criteria IDF.


А. Overweight of central type.

B. High level of triglyceride .

C. Low of level of CLHD

D. High level of glucose in plasma blood on an empty stomach..

E. Arterial hypertension.Артериальная гипертензия.


Task 2.

In a patient with metabolic syndrome was made lot of examination: measured the circumfluence of waist, measured BP, examined a lipid profile, the level of glucose on an empty stomach, leaded per oral glucose tolerant test. What is the examination which was leaded is not necessary for determination of presence of metabolic syndrome:

А. Measuring of circumfluence of waist

B. Measuring of BP

C. Measuring of lipid profile.

D. Determination of glucose level on an empty stomach.

E. Measuring of glucose tolerant test per oral.


Task 3.

In a patient D, theraputist determined the presence of break of hydrocarbon changes. What is the criteria of metabolic syndrome among the laboratory measuring in this patient :


А. High level of glucose in blood plasma on an empty stomach.

B. High level of postproindial glucose in blood plasma.

C. High level of basal insulin in blood plasma on an empty stomach.

D. High level of glycated hemoglobin in blood plasma on an empty stomach.

E. High level of rennin in blood plasma on an empty stomach.


Task 4.

In a patient N, 58 years old, who suffer from diabetes mellitus of 2 type on the background of metabolic syndrome developed hypoglycemic coma.What kind of breath was determined in a patient during objective examination?


А. Normal

B. Chein-Stoksa’s

C. Biot’s

D. Kussmaulya’s

E. Ortopnoe


Task 5.

In a patient D. who has overweight, a doctor diagnosed diabetes mellitus of II type. Which medicine is the first treatmen for this patient?


А. Roziglitazon

B. Basal insulin

C. Diabeton MR

D. Glyukofash

E. Glikoza


III. Contains of study


For reach of knowledge aims it is necessary to learn next theoretical questions.:

  1. Ways of clinical, laboratory and instrumental diagnosis of MS and DM..

  2. Differential diagnosis of MS and DM.

  3. Classification of MS and DM.

  4. Epidemiology, etiology and pathogenesis of MS and DM.

  5. Principals of study of MS and DM.


Information which is needed for learning the theoretical questions, you can find in next literature issues:

  1. I.V.Chazova, V.B. Michka. Metabolic syndrome.- M.: Media Medica, 2004.-163 p.

  2. Principals of cardiology. Practice. Second publishing/ Under red K. Rozendorf.- Lvov: Medecine of world, 2007.- P. 511-532.

  3. Textbook on cardiology / Under red V.N.Kovalenko.-K.: Morion, 2008.- P. 228-242.

  4. Recommendation of Ukrainian association of cardiologist and Ukrainian association of endocrinologists “Diagnosis and treatment of metabolic syndrome, diabetes mellitus, prediabetes and cardiac-vascular diseases” / Under red of Mitchenko E.I., Karpachov V.V., Bagriy A.E., Zvyagina T.V.- Kiev, 2008. – 29p.

  5. Lection on hospital therapy.

  6. Structure-logical net of «Metabolic syndrome» (Addition 1).

  7. Diagnostic algorithm of «Metabolic syndrome» (Addition 2).

  8. Criteria of metabolic syndrome (Addition 3).

  9. Algorithm of examination of a patient with MS, DM and ICD. (Addition 4).

  10. Algorithm of metabolic treatment the patient with diabetes mellitus 2 type (Addition 5).



Then you have to solve some tasks and to check right answers on the example.

Task 1.

Patient K., who has in anamnesis diabetes mellitus and arterial hypertension, a doctor thinks about metabolic syndrome. What kind of additional examination we have to make for determination of presence of abdominal overweight:


А. Determine the weight of the patient

B. To measure the circumfluence of waist.

C. To measure the circumfluence of hips.

D. To solve the coefficient of volume of waist/hips

E. To solve the index of weight


Task 2.

In a patient M, during the examination, determined metabolic syndrome. Which combination of 3 clinical symptoms which take place in a patient let us diagnosis metabolic syndrome.

А. Overweight of central type + anemia + hypertriglyceridemia.

B. Overweight of central type + hypertriglyceridemia. + hyperglycemia.

C. Hypertriglyceridemia+ arterial hypertension + hyperglycemia .

D. Hypertriglyceridemia + arterial hypertension + anemia.

E. Overweight of central type + arterial hypertension + anemia.


Task 3.

Patient 48 years old , entered to thee hospital Больная 48 лет, complaints on headache, high fatigability, breathless and heart beat during fast walking, break of menstrual cycle. She feels bad after nervous-emotional stress. During objective examination – hight =172 cm, weight 100 kg. Distribution of fat tissues is irregular – with predomination on the abdominal part. BP 160/90 mm. hg.cl. Data of lipidogramma: cholesterol common 7,0 mmol/l, triglyceride 2,4 mmol/l, cholesterol of lipoprotein of high density – 0,86 mmol/l.

What kind of syndrome take place in this patient?


А. Alimentary-constitutional overweight of II degree

B. Neurocirculatory dystonia on hypertonic type

C. Hypotalamic puberties syndrome.

D. Metabolic syndroem

E. Break of ovarian-menstrual cycle


Task 4.

A patient, who suffer from metabolic syndrome with the diabetes mellitus 2 type, took glibenklamid 15 mg per day for a long time . He felt good. Suddenly, at 11 a.m. he felt bad: appeared cold sweat, tremor of extremities, and a patient lost confidence. What a doctor has to do first of all?


А. To insert insulin

B. To insert 40% solution of glucose intravenously stream

C. To start intravenous introduction of insulin with glucose

D. To call the laborant and waits for results of blood analisis

E. To give oxygen


Task 5.

During the prescription of therapy to the patient with metabolic syndrome, a doctor out 5 main aims:

1. Normalization of weight

2. To increase physical activity

3. Antihypertension therapy

4. Low lipid therapy

5. Hypoglycemic therapy

Which aim is not necessary and we can do it later?


А. – 1

B. – 2

C. – 3

D. – 4

E. – 5


An example of answer to the task №1.

The right answer is B.To measure the circumfluence of waist. An overweight related with insulin resistance and metabolic syndrome. But, overweight on abdominal type in a main korrelirate with metabolic syndrome, then increasing of index of weight. That’s why usual measuring of circumfluence of waist is recommended for determination of “weight” component of metabolic syndrome.


Short methodical review to the guidance of lesson on the topic “Metabolic syndrome”


In the beginning of the lesson the professor leads checking of correction of level of knowledge by tests. Then students make self examination of patient, after this you make the discussion of the patient and correction by the professor of a lesson.

For the strengthening of knowledge the professor makes the conclusion of self work of students.


Addition 1


Structure-logical net of «Metabolic syndrome»



MS







Leading symptoms and syndroms












Overweight of central type

High level of triglycerid.

Low level of

CLHD




Arterial hypertension

High level of glucose on an empty stomach










Break of hydrocarbon and lipid changes







Anamnesis







Increasing of IWB, specific therapy cause of dislipidemia, hypotension therapy cause of AG, positive glucosetolerant test, DM 2 type, menopause in woman.







Data of additional methods of examination




Laboratory

Instrumental





Lipid profile of blood

крови ( increasing of level of TG and low of level CLHD and high level of CLLD); determine of glucose on an empty stomach, glycated hemoglobin and basal insulin in blood, determination of postprandial glucose in plasma blood.


Measuring of height, weight of patient. Measuring of circumfluence of waist Measuring of BP, EKG ( hypertrophy LV), echoKG (hypertrophy of LV, diastole disfunction of LV). КТ and МRТ (specific of fat distribution).
















Differential diagnosis on the diagnosis algorithm: metabolic syndrome, diabetes mellitus 2 type.







Classification of metabolic syndrome










Overweight

Dislipidemia

Arterial hypertension










Break of tolerance to the glucose or diabetes melitus









Principals of treating the patient




Prophylactic




Symptomatic therapy

Pathogenetic therapy







Diet therapy. Increasing of physical activity Sanitary lessons. Self control for the level of glycemia and weight.

Antihypertension therapy:

IAPF, BRAT, antagonists of calcium prolonged action, cardioselective β-blocators, tiaaid diuretics, medicine of central action (activators imidozopin receptors). Hypolypid therapy. DM type 2: Sulfaniluretic, biguanids,glytozones,insulin - sulfanilurine, ingibitors of alfaglukozidaza.

Normalization of weight:

- orlistat (inhibitor of stomach lipaz);

- sibutramin (inhibitor of back capture of serotonin );

- rimonobant (antagonist of endokanaboind receptors)



Addition 2.


Diagnostical algorithm with syndrome «Overweight»


Nozological list


  1. Hypofizar overweight

  2. Alimentary overweight

  3. IDH: aterosclerotic cardiosclerosis

  4. Hypertension disease

  5. Diabetes melitus

  6. Metabolic syndrome



Overweight



Tumor of hypophysis, found on KT




Regular distribution of fat tissues







NO YES


There are plaques in coronary or carotids arteries

2


Yes





1
YES NO


Narrowing of arteries of nervous tunic of eyeball, edema of disk of visual nerve.

3





YES NO


Increasing of glucose of blood plasma on an empty stomach ≥7,0 mmol/l.

4





5


YES NO


Overweight on abdominal type




6
YES


Addition 3


Criteria of metabolic syndrome, recommended by International Diabetic federation (IDF) 2007 year.


  1. The presence of overweight of central type, determined by the circumfluence of waist ( in cm) ≥ 90 cm in men ≥ 80 cm in woman

  2. The presence any 2 factors from 4 listed:

    1. high level of TG: ≥ 1,7 mmol/l or on the background of specific gypolipidemia therapy.;

    2. low level of CLHD< 1,03 mmol/l in man and < 1,29 mmol/l in woman or specific therapy cause of lipidemia.

    3. Arterial hypertension (SBP≥ 130 mm. hg.cl. or DBP ≥ 85 mm.hg.cl.) or hypotension therapy cause of before diagnosed arterial hypertension.

    4. High level of glucose in blood plasma on an empty stomach ≥ 5,6 mmol/l or before diagnosed diabetes mellitus 2 type.



Addition 4


Algorithm of examination of a patient with DM, MS and IDH


IDH + DM







Main diagnosis of DM ± IHD



Main diagnosis

IHD ± DM


DM is not diagnosted: Level of lipids and glucose in blood, HbAlc.


DM is diagnosted:

Scrining of nefropathia During not full control of glycemia

(HbAlc ≥ 7,0)



IHD is not diagnosted:

EKG, EchoKG, test with physical

training


IHD is diagnosted :

EKG, EchoKG, training test with positive answer




Without path changes

Path changes are found








Next examinationюдение

Consultation of cardiologist, invasive or antiishemical therapy

Consultation of endocrinologysstt







First found of DM or break of tolerance to glucose + MS

Without changes







Examination of cardiologyst







Conultation of endocrinologist



Addition 5


Algorithm of treatment of metabolic syndrome DM 2 type

Diagnosis (2 type DM)


Modification of life style and metformin


HbA1c≥7%

Yes

No

add biguanides

add basal insulin

add glitazones

HbA1c≥7%

Yes

No

HbA1c≥7%

Yes

No

HbA1c≥7%

Yes

No

intensive insulinotherapy

add biguanides

add glitazones

add basal insulin

Add basal insulin or intensive insulinotherapy

No

Yes

HbA1c≥7%

No

Yes

HbA1c≥7%







^ The sum test control


Task 1.

Patient C. Has a metabolic syndrome was determined the break of results of lipid changes. Changes of which 2 main results of lipid changes confirmed the diagnosis of a doctor?


А. OH + CH LHD

B. OH + TG

C. TG + CH LLD

D. TG + CH LHD

E. CH LLD + CH LHD


Task 2.

During the screening of the patient with arterial hypertension in a quantity of man and woman was determined a metabolic syndrome. Which results of level of CH LHD were taken by the doctor to determine the diagnosis?


А. < 0,9 mmol/l in man and < 1,0 mmol/l in woman

B. < 0,9 mmol/l in man and < 1,29 mmol/l in woman

C. < 1,03 mmol/l in man and< 1,0 mmol/l in woman

D. < 1,03 mmol/l in man and< 1,29 mmol/l in woman

E. < 1,0 mmol/l in man and< 1,29 mmol/l in woman


Task 3.

During the examination of a patient В was found 4 cardiometabolic factors of risk. Which factor from listed below is not a factor of risk of metabolic syndrome?


А. Overweight

B. Proteinuria

C. Dislipidemia

D. Arterial hypertension

D. Break of tolerance of glucose.


Task 4.

In patient D. determined the abdominal type of overweight. What the minimal results of circumflex of waist in man could prove the presence of abdominal overweight?

А. > 80 cm

B. > 88 cm

C. > 94 cm

D. > 102 cm

E. > 112 cm


Task 5.

In patient М. with metabolic syndrome during the examination was determined an overweight. After the counting of IWB, doctor determined that it is 35 kg/m². What could be the reason of such a weight in a patient?


А. Insulinresistance.

B. Dislipidemia.

C. Disproteinemia

D. Gyperurikemia.

E. Hyperkoagulation.


Task 6.

During the examination of the patient BP= 170/100 mm.hg.cl., IWB =30 kg/m². During next examination of blood OH - 6,5 mmol/l,CH LHD – 0,9 mmol/l, glucose of blood – 6,5 mmol/l. About what disease we havt to think?


А. Arterial hypertension

B. Metabolic syndrome

C. Cerebral aterosclerosis

D. Diabetes melitus

E. Kon disease


Task 7.

A patient D., with metabolic syndrome and DM 2 type was determined next symptoms: hyperglycemia, hyperinsulinemia, glucosuria, poliuria, polidipsia..What the symptom is not main for DM 2 type?


А. hyperglicemia

B. hyperinsulinemia

C. glucosuria

D. poliuria

E. polidipsia


Task 8.

During the examination of a patient B., 57 years old, was found an abdominal type of overweight and increase BP up to 180/100 mm.hg.cl. A doctor decided to determine the level of hormones in blood for determination of metabolic syndrome in a patient. The increasing of which hormone in blood could prove the diagnosis of a doctor?


А. Glucagons

B. Aldosterone

C. Insulin

D. Tiroksin

E. Cortisone


Task 9.

In a patient D. 20 years old, who has IWB = 32 kg/m², was diabetes mellitus 2 type under a question. But, during the examination was found that a patient suffer from diabetes mellitus of second type. What is a main pathophisiology difference between DM 1 type and DM 2 type?

A. Low level of C-peptide

B. Pathology of insulin receptors.

C. Resistance to the ketoacidosis

D. Resistance to the insulin

E. Absolute deficit of insulin


Task 10.

In a patient D., 46 years old, who has an abdominal type of overweight, arterial hypertension and hypertrigliceridemia, level of glucose in blood on an empty stomach during mutual examination was in normal. In what interval was the concentration of glucose in the patient?


А. 2,5 – 3,5 mmol/l

B. 3,6 – 5,5 mmol/l

C. 5,6 – 7,5 mmol/l

D. 6,6 – 8,5 mmol/l

E. 7,6 – 8,5 mmol/l




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