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Guidelines for Third-year Students of the Medical Department

 

Before you read

 

1. Answer these questions.

a) Which is the correct description of a merger?

When one company gains control of another by buying the majority of its shares.

When two companies, often equal in size, combine to form one new company.

b) What word or words fit the other description above?

 

2. Discuss these questions.

a) What kinds of banks and financial institutions are there in your country?

b) Is there a trend in your country for smaller banks to merge or be taken over by larger ones?

 

Reading tasks

 

A. Understanding main points

1. Mark these statements T (true) or F (false) according to the information in the text. Find the part of the text that gives the correct information.

a) In investment banking, it is important to be very big in order to be competitive.

b) Middle-sized banks may survive, but small ones have no chance.

c) Barclays, a UK bank, has increased its investment banking activities.

d) It is difficult for middle-sized banks to pay the high salaries demanded by stock traders.

e) Edward Crutchfield's comments were about retail banking.

f) Mergers between retail banks are mostly international.

g) There are more financial institutions in relation to the population in France than in the USA.

h) Irish banks need to become international if they want to expand.

i) In retail banking it is difficult to save costs by increasing size.

j) Credit card processing is cheaper when done on a large scale.

k) One of the biggest costs for banks nowadays is software development.

 

2. The article can be divided into two sections, each dealing with a different aspect. These are marked I and II in the text. What is each section about?

 

3. Find three kinds of bank which are mentioned in the article.

 

Survival of the biggest

A wave of M&A has reshaped the industry, but stuck largely to national deals

How big is big? A wave of mergers and acquisitions has completely reshaped the face of the international finance industry. Across a range of financial sectors, the tables are being cleared for a handful of giants, with room still for niche players but little space for the middle-sized.

(I) The most dramatic changes came in the investment banking area, where a range of specialised or regional investment banks found new commercial banking parents. Many investment bankers now believe the battle for membership of dominant firms is reaching its closing stages.

'In a lot of industries – telecoms, pharmaceuticals, for example – it is not unusual to see five global giants survive. Five seems to be the magic number', says Hans de Gier, head of Warburg Dillon Read investment bank. 'In investment banking, too, you will see a handful of global firms which have the cost base but also have the revenue base to support this vision.'

Some banks have already reached the conclusion that they cannot realistically hope to be part of that select group, and have scaled back their investment banking ambitions. In the UK, both Barclays and National Westminster have sold most of their equity operations and now concentrate solely on debt – more closely linked to their traditional banking business.



Spiralling pay packets for traders and investment bankers have made it difficult for the midsized contenders to stay in the race. They have to pay people just as much or more, but don't get as much revenue out of them as a global firm.

(II) In the retail banking sector, some of the talk sounds familiar. Edward Crutchfield, chairman of First Union, recently warned smaller traditional banks that they were a 'declining, dying business. Merger mania will last until there are 10 or 12 or maybe dominant financial services'.

But with very few exceptions, consolidation in the retail banking sector remains national in character. ING’s takeover of Banque Bruxelles Lambert in Belgium represents one example of a cross-border deal. But most efforts to cross national boundaries have not worked.

In the US, there remains plenty of room for consolidation without stretching overseas. The number of commercial banks has shrunk from 11,462 in 1992 to 9,215 this year, but that still leaves the US with far more financial institutions in proportion to its population than comparable countries.

In countries such as the UK and France there may be room for further consolidation, but banks in the Netherlands and Ireland already have to look abroad for a second home market.

Retail banking has proved resistant to economies of scale. In specific activities such as credit card processing, unit costs fall rapidly with size. In banking more generally, however, the complexity of operations reduces the benefits resulting from size.

That may be changing with increasing IT use in banking. The cost of software development is one of the biggest factors with 14 banks estimated to be spending more than $1 billion a year on IT.

IT = Information Technology

 

Vocabulary tasks

 

A. Key terms

Match these terms with their definitions.

1. consolidation 2. equity operations 3. unit cost 4. cost base 5. niche 6. parent company 7. retail 8. investment bank 9. commercial bank a) division of a bank that deals with share issues and share trading b) bank that acts as an intermediary between companies and the investing public c) bringing together of two or more companies, as in a merger d) provision of basic banking services to individuals and companies e) place in the market for a specialised product or service f) company which owns more than 50% of another company g) total cost divided by the number of items that are handled h) large size providing the means for costs to be minimised i) bank involved in international trade and corporate banking

 

B. Word search

Find a word or phrase in the text that has similar

1. people or companies who compete to win something (para 5) – c…

2. temporary phase when everybody wants to merge (para 6) – m… m…

3. merger or takeover between companies in different countries (para 7) – c…-b… d…

4. principle that the larger a companies is, the lower its average costs are (para 10) – e… of s…

 

C. Word fields

Write these words or phrases in the appropriate columns.

expand / reduce / scale back / shrink / stretch / spiral / decline / fall

Words meaning to get bigger Words meaning to get smaller
   

 

D. Understanding expressions

Choose the best explanation for each of these words or phrases from the text.

1. wave of mergers

a) large number of mergers taking place all at once b) tendency for a few mergers to take place

2. reshaped the face of the international financial industry

a) changed it completely b) improved it

3. tables are being cleared

a) new game is about to start with different players taking part b) the game is over

4. reaching its closing stages

a) has finished b) nearly at an end

5. handful

a) five b) small number

6. vision

a) view of the future b) plan or policy

7. concentrate solely on

a) concentrate mainly on b) concentrate only on

8. comparable countries

a) countries that are similar in size b) countries that have a similar level of economic development

9. has proved resistant to

a) has benefited from b) has been unaffected by

10. unit costs fall rapidly with size

a) unit costs fall rapidly as size increases b) unit costs fall rapidly as size decreases

 

Over to you

1. Discuss what changes have taken place since 1997 regarding the shape of the financial industry.

2. What do you think the financial industry will look like in ten years’ time? Will there be many more changes? Give your opinion.

 

Guidelines for Third-year Students of the Medical Department

 

Subgect Propedeutics of internal medicine
Modul ¹
Enclosure module ¹
Topic Clinical, laboratory and instrumental examinations of patients with aortic valve disease.
Course
Faculty Medical ¹ 1

 

Methodical recommendations are made in accordance with educationally-qualifying descriptions and educationally-professional programs of preparation of the specialists ratified by Order MES of Ukraine from 16.05 2003 years ¹ 239 and experimentally - curriculum, that is developed on principles of the European credit-transfer system (ECTS) and Ukraine ratified by the order of MPH of Ukraine from 31.01.2005 year ¹ 52.

 

 

Vinnytsya – 2007


 

  1. Importance of the topic

Valve aortic diseases are important structural pathology of the heart. They can be formed due to different pathological process and usually could not be resolved without surgery. Knowledge about causes, hemodynamics, symptoms and signs of the aortic valve diseases has a great role in the study of the cardiovascular diseases.

  1. Concrete aims:

To learn and understand hemodynamics, symptoms, signs, laboratory and instrumental data at patients with the aortic valve diseases.

Basic training level

 

Previous subject Obtained skill
Normal anatomy Anatomy of the heart, its conduction systems
Normal physiology Principles of the heart automaticity, conductivity
Histology histological structure of the heart
Propedeutics to internal diseases Symptoms of the cardiovascular diseases, data of general and local visual inspection, palpation, percussion, auscultation of the heart, main ECG-signs, Echo-CG signs of the aortic valve diseases

 

4. Task for self-depending preparation to practical training

4.1. List of the main terms that should know student preparing practical training

 

“Cat purring” Capillary pulse cardiac asthma
Systolic murmur syncope ‘parvus and tardus’ pulse
Diastolic murmur carotid pulsation (‘pulsus celer, altus, magnus’
Pulmonary edema Traube’s sign Flint murmur

 

4.2. Theoretical questions:

  1. Causes and hemodynamics of aortic stenosis.
  2. Symptoms and signs of aortic stenosis.
  3. Data of additional methods of investigation at patients with aortic stenosis.
  4. Causes and hemodynamics of aortic regurgitation.
  5. Symptoms and signs of aortic regurgitation.
  6. Data of additional methods of investigation at patients with aortic regurgitation.

4.3. Practical task that should be performed during practical training

1. Collecting symptoms at patient with aortic valve diseases

2. Revealing signs of the aortic valve diseases

3. Assessing data of ECG, Echocardiography and X-ray examination of the aortic valve diseases patient

 

Topic content

Causes of aortic stenosis:

Senile calcification is the commonest

rheumatic fever,

congenital aortic bicuspid valve (associated with coarctation of the aorta),

congenital stenosis of valve cusps,

septic endocarditis.

Hemodynamics of the aortic stenosis is impaired if the aortic opening is decreased from normal 3 sm2 until 1,00 -0,75 sm2 and less. During systole blood doesn’t go to the aorta completely. Increased left ventricular pressure tries to overcome the resistance of the narrowed valvular opening. The massive hypertrophy of the left ventricle has being developed. The added workload increases the demand for oxygen, and diminished cardiac output causes poor coronary artery perfusion, ischemia of the left ventricle, and left ventricular failure.

Later compensatory ability of the left ventricle has been diminished and its cavity has been enlarged. It is developed diastolic dysfunction of the left ventricle. Relative mitral regurgitation is formed and results in increased pulmonary artery pressure, eventually leading to left and right ventricular failure.

Symptoms and signs of aortic stenosis: Symptoms appear if aortic stenosis has decompensated. There is dyspnea on exertion, paroxysmal nocturnal dyspnea, fatigue, palpitations, angina pectoris, headache, dizziness, and syncope.

Dizziness and syncope can be due to insufficiency of the cerebral circulation. The angina occurs when hypertrophy myocardium of the left ventricle needs more oxygen than coronary arteries can get because cardiac output is low than normal.

Dyspnoea appears at blood congestion in the pulmonary veins resulting in reduction of the pulmonary tissue elasticity. At first, dyspnoea appears only on physical effort, later at rest when the patient is lying and it is relieved if patient sits (orthopnea). At last dyspnea does not disappear even in an upright position of the patient. Dyspnoea is frequently mixed with difficulty in inspiration and expiration as well as involvement of the auxiliary respiratory muscles in the act of respiration.

Paroxysmal dyspnea sometimes appears suddenly at night as attack of cardiac asthma with dry cough or heamoptysis. The most severe complication of this disease is pulmonary oedema.

At the visual examination a pale skin due to low blood filling of peripheral arterioles is observed.

Pulse is low-volume, slow rising with narrow pulse pressure (‘parvus and tardus’). Systolic blood pressure is decreased and diastolic blood pressure is normal.

Apex beat is heaving, displaced to the left, and resistant. You can obtain systolic trembling of chest at the base region named “cat purring”. It is palpation sensation of murmur which appears during going flow blood through narrowing aortic opening.

The left border of relative heart dullness shifts left due to hypertrophy left ventricle.

On auscultation diminished S1 (muscle component) on the apex, a quiet S2 on the aorta (sometimes inaudible due to calcified and unmoving valve) are heard. There is rough ejection systolic murmur heard at the base, left sternal edge and the aortic area, radiates to the carotids and interscapular region.

Chest X-ray examination: Aortic configuration of the heart at the front position: accentuated waist of heart and left ventricle enlargement, valvular calcification, post-stenotic dilatation of ascending aorta, and pulmonary vein congestion are recognized.

ECG: There is left ventricle hypertrophy, chronic coronary insufficiency (depressed ST segment and negative T-wave in I, II, AVL, V4-6). Sometimes p-mitrale can be if relative mitral regurgitation has been developed.

Echocardiography: There is thickened calcified aortic valve and thickened left ventricular wall, interventricular septum. Reduction of aortic opening square (normal – 3 cm2) are revealed.

Causes of aortic regurgitation:

Rheumatic fever,

infective endocarditis,

syphilitic aortitis

hypertension,

connective tissue disorders (rheumatoid arthritis, systemic lupus erythematosus, Marfan syndrome),

congenital (may be associated with other defects, such as ventricular septal defect),

trauma with aortic dissection.

Hemodynamics of the aortic regurgitation: Blood flows back into the left ventricle during diastole, causing fluid overload in the ventricle, which dilates and hypertrophies. The excess volume causes fluid overload in the left atrium and, finally, the pulmonary system. Left ventricular failure and pulmonary edema eventually result.

Pulmonary hypertension augments loading of right ventricle and causes its hypertrophy and failure.

Symptoms and signs of the aortic regurgitation: Symptoms appear if aortic regurgitation has decompensated and congestive changes in pulmonary circulation are developed.

The first complains are fatigue, palpitation and heaviness in the heart region which increase in the reclining position. The characteristic complain is an angina which is caused by worsened coronary circulation of the hypertrophied left ventricle and low diastolic blood pressure in the aorta.

Dizziness, pulsating headache and syncope can be due to insufficiency of the cerebral circulation.

Dyspnea, cough, cardiac asthma attack occur when cardiac decompensation have been developed. Finally, heaviness in the right under rib and leg edemas appear as symptoms of the right ventricle failure.

At the visual examination a pale skin due to low blood filling of peripheral arterioles during diastole and their reflex spasm is observed. There is carotid pulsation (Corrigan’s sign), head nodding (de Musset’s sign), capillary pulsation in nail beds (Quincke’s sign), pulsatile narrowing and widening pupils, pulsatile dermography spot. All this signs occur because of quick fluctuation of blood pressure.

Pulse is rapidly rising, collapsing (water-hammer), large, high and frequent (‘pulsus celer, altus, magnus’). Systolic blood pressure is decreased and diastolic blood pressure is normal.

Apex beat is heaving, wide, undisplaced to the left and downward, and resistant.

The left border of relative heart dullness drifts left and downward due to enlarged left ventricle.

On auscultation the weakened S1on the apex (due to hypertrophy and overfilling of the left ventricle), and weakened S2 at the 2nd intercostals space near right edge of the sternum (due to absence of closing the aortic valve) are heard. If the aortic valve has broken significantly S2 over aorta couldn’t be heard.

There is high-pitched soft blowing early diastolic murmur at the right 2nd intercostals space near sternum. It is heard best in expiration, with patient sitting forward and radiates to the 5th point of auscultation.

In severe aortic regurgitation an Austin Flint murmur (due to the fluttering of the anterior mitral valve cusp caused by regurgitation stream) may be heard.

If relative mitral regurgitation has developed the systolic murmur can be heard on the apex.

There are associated auscultation phenomena: ‘pistol shot’ sound over femoral arteries (Traube’s sign) and femoral diastolic murmur as blood flows backwards in diastole (Duroziez’s sign).

Arterial blood pressure always is changed: systolic is high and diastolic is low → wide pulse pressure.

Chest X-ray examination: Aortic configuration of the heart at the front position: accentuated waist of heart and left ventricle enlargement dilated ascending, and pulmonary vein congestion are recognized.

ECG: There is left ventricle hypertrophy, chronic coronary insufficiency (depressed ST segment and negative T-wave in I, II, AVL, V4-6). Sometimes p-mitrale can be if relative mitral regurgitation has been developed.

Echocardiography: aortic valvular insufficiency, left ventricular enlargement, alteration in mitral valve movement (indirect indication of aortic valve disease) and mitral enlargement and thickening, pulmonary hypertension signs are revealed. Doppler echo allow assessing size and sites of regurgitation. Cardiac catheterization confirms diagnosis (aortic regurgitation, anatomy of aortic root reduction in arterial diastolic pressures, and increased left ventricular end-diastolic pressure), excludes other valve disease, assesses coronary artery disease.

 

Reference source

o Handbook of diseases.-.2nd ed.- Springhouse Corporation, 2000 – P.892-895


Materials for self-control (added)

1. How is the systolic murmur conducted at patient with aortic stenosis?

A. along the right edge of breastbone;

B. to the Botkin-Erb point;

C. to the vessels of neck;

D. to the lift axillary area;

E. not conducted.

 

2. How is the first sound changed at the patient with aortic stenosis?

A. Amplified;

B. Diminished;

Ñ. Split;

D. not changed;

E. Depend on clinical situation.

 

3. How is the second sound changed at the patient with aortic stenosis?

A. increased above the aorta

B. increased above the pulmonary artery;

C. diminished above the aorta;

D. diminished above the pulmonary artery;

E. not changed.

 

4. What are ECG changes at the patients with aortic stenosis?

A. hypertrophy left atrium

B. hypertrophy of right atrium;

C. hypertrophy of right ventricle;

D. hypertrophy of left ventricle;

E. all mentioned above.

5. What border of the relative heart dullness is shift at the patient with aortic stenosis?

A. right is shift right

B. left is shift left and downward;

C. upper is shift upward;

D. upper is shift upward and right is shift right;

E. left is shift left.

 

6. How is the first sound changed at the patient with aortic regurgitation?

A. Amplified;

B. Diminished;

Ñ. Split;

D. not changed;

E. Depend on clinical situation.

7. What border of the relative heart dullness is shift at the patient with aortic regurgitation?

A. right is shift right

B. left is shift left and downward;

C. upper is shift upward;

D. right answers A, B, and C;

E. borders of the relative heart dullness are not changed.

8. What murmur at the aorta point can be heard at the patient with aortic regurgitation?

A. systolic

B. diastolic;

C. systolic and diastolic;

D. murmur is absent;

E. depend on clinical situation

9. Which area is the murmur at the patient with aortic regurgitation conducted to?

A. neck vessels

B. axillary region

C. interscapular region

D. Botkin-Erb point

E. is not conducted.

10. What are the symptoms of decompensated aortic stenosis?

A. Dyspnea and fatigue,

B. Palpitation,

C. Chest pain,

D. Faintness

E. All mentioned above

11. What are the symptoms of decompensated aortic regurgitation?

A. Dyspnea and cough,

B. Palpitation, heaviness in the heart region

C. Cardiac asthma attack,

D. Faintness, dizziness

E. All mentioned above

12. What are the main causes of aortic regurgitation?

A. Rheumatic fever,

B. infective endocarditis, syphilitic aortitis

C. connective tissue disorders (rheumatoid arthritis, systemic lupus erythematosus, Marfan syndrome),

D. congenital (may be associated with other defects, such as ventricular septal defect),

E. all mentioned above

13. What are the main causes of aortic stenosis?

  1. Senile calcification is the commonest
  2. rheumatic fever,
  3. congenital valve diseases

D. septic endocarditis.

E. all mentioned above

14. How is color of skin changed at patients with aortic valve diseases?

A. Became bluish

B. Become reddish

C. Become yellowish

D. Became pale

E. Nothing from above.

15. Capillary pulse is a sign of…

A. Aortic stenosis

B. Mitral stenosis

C. Mitral regurgitation

D. Pulmonary hypertension

E. Aortic regurgitation

16. ‘Carotid dance’ (carotid pulsation) is a sign of …

A. Mitral stenosis

B. Pulmonary hypertension

C. Aortic regurgitation

D. Aortic stenosis

E. Mitral regurgitation

17. How is blood pressure changed at patient with aortic stenosis?

A. Systolic increased, diastolic normal

B. Systolic decreased, diastolic normal

C. Systolic normal, diastolic increased

D. Systolic normal, diastolic decreased

E. Systolic increased, diastolic decreased

18. What murmur at the aorta point can be heard at the patient with aortic stenosis?

A. systolic

B. diastolic;

C. systolic and diastolic;

D. murmur is absent;

E. depend on clinical situation

19. How is the second sound changed at the patient with aortic regurgitation?

A. increased above the aorta

B. increased above the pulmonary artery;

C. diminished above the aorta;

D. diminished above the pulmonary artery;

E. not changed.

20. Systolic ‘cat purring’ is a sign of…

A. aortic regurgitation

B. mitral regurgitation

C. arterial hypertension

D. aortic stenosis

E. mitral stenosis


Date: 2014-12-21; view: 1569


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