METHODICAL INSTRUCTION FOR STUDENTS OF THE 6 COURSE
FOREIGN STUDENTS’ FACULTY
Module 3. CURRENT PRACTICE OF INTERNAL MEDICINE
Content module 7. Differential diagnosis and management of patients with blood diseases
LESSON № 1 (PRACTICAL – 6 HOURS)
Theme 24: Management of patients with anemia
Aim: to develop skills and to acquire experience relevant to management of patients with different types of anemia.
Professional orientation of students: Anemia is a prevalent condition with a variety of underlying causes. Once the etiology has been established, many forms of anemia can be easily managed by the family physician. Iron deficiency, the most common form of anemia, may be treated orally or, rarely, parenterally. Vitamin B12 deficiency has traditionally been treated with intramuscular injections, although oral and intranasal preparations are also available. The treatment of folate deficiency is straightforward, relying on oral supplements. Folic acid supplementation is also recommended for women of child-bearing age to reduce their risk of neural tube defects. Current research focuses on folate’s role in reducing the risk of premature cardiovascular disease. Finding out the anemia in time prevents the difficult changes of blood system and all organism, diminishes temporal disabled of population. The general physician of polyclinic is responsible for dyspancerisation of the patients with anemia. Anemia is very often met in 20% women of the developed countries and in 50% women of the non-developed countries. More than 50% patients with chronic diseases and tumors. Considerably worsens quality of life and capacity.
Methodology of Practical Class
Introduction by the teacher, control the initial level of knowledge – 09.00-09.30
Individual students’ work with patients – 09.30-12.00
Break – 12.00-12.30
Seminar (discussion of theoretical questions, practical work with patients) – 12.30-14.00
Break – 14.00-14.15
Individual work 1415-1500 (students who didn`t pass the tests in Moodle system, complete the individual work).
Algorithm of students’ communication with patients with pathology in subject (communication skills):
During examination of the patient students have to use such communicative algorithm:
Complaints and anamnesis taking in patients
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Take complaints and anamnesis in a patient.
5. Explain to the patient results of his/her lab tests correctly and accessibly.
6. Explain to the patient your actions concerning him/her (the necessity of hospitalization, certain examinations and manipulations), which are planned in future.
7. Conversation accomplishment.
Objective examination:
Physical methods of examination of patients with internal diseases
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Explain to a patient, what examinations will be carried out and get his/her informed consent.
5. Find a contact with the patient and make an attempt to gain his/her trust.
6. Inform about the possibility of appearing of unpleasant feelings during the examination.
7. Prepare for the examination (clean warm hands, cut nails, warm phonendoscope, etc.).
8. Examination (demonstration of clinical skill).
9. Explain to the patient results of his/her lab tests correctly and accessibly.
10. Conversation accomplishment.
Estimation of laboratory and instrumental investigations
Informing about the results of examination of patients with internal diseases
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Explain to a patient results of his/her lab tests correctly and clearly.
5. Involve the patient into the conversation (compare present examination results with previous ones, clarify whether your explanations are clearly understood).
Planning and prognosis the results of the conservative treatment
Friendly facial expression and smile.
1. Gentle tone of speech.
2. Greeting and introducing.
3. Correct and clear explanation of necessary treatment directions.
4. Discuss with a patient the peculiarities of taking medicines, duration of their usage, possible side effects; find out whether your explanations are clear for him/her or not.
5. Conversation accomplishment.
Work 1. Work at the patient’s ward. The student collects the complaints, anamnesis of disease and life, perform objective examination of the patient, identify the main syndrome, formulate preliminary diagnosis and prescribe plan of investigations.
Work 2. The student estimates results of laboratory and instrumental investigations, makes a differential diagnosis and formulates the clinical diagnosis, based on the diagnostic criteria of the disease.
Work 3. The student prescribes appropriate treatment and defines individual management program for patient.
Individual Students Program
· Under the tutor’s supervision students should be able to elicit the patient’s chief complaint, history of present illness, past medical history, social, family, occupational histories and complete a review of systems.
· Perform a physical examination in a logical, organized and thorough manner.
· Demonstrate the ability to construct an assessment and plan for an individual patient organized by problem, discussing the likely diagnosis and plan of treatment.
· Demonstrate the ability to record the history and physical in a legible and logical manner.
· Demonstrate the ability to write daily progress notes on the ward and appropriate outpatient progress notes.
· Orally present a new patient’s case in a focused manner, chronologically developing the present illness, summarizing the pertinent positive and negative findings as well as the differential diagnosis and plans for further testing and treatment.
· Orally present a followup patient’s case, focusing on current problems, physical findings, and diagnostic and treatment plans.
· Diagnostic Decision Making
· Formulate a differential diagnosis based on the findings from the history and physical examination.
· Use the differential diagnosis to help guide diagnostic test ordering and its sequence.
· Participate in selecting the diagnostic studies with the greatest likelihood of useful results.
· Recognize that tests are limited and the impact of false positives/false negatives on information.
· Test Interpretation
· Describe the range of normal variation in the results of a complete blood count, blood smear, electrolyte panel, general chemistry panel, electrocardiogram, chest X–ray, urinalysis, pulmonary function tests, and body fluid cell counts.
· Describe the results of the above tests in terms of the related pathophysiology.
· Understand test sensitivity, test specificity, pre-test probability and predictive value.
· Understand the importance of personally reviewing X-ray films, blood smears, etc., to assess the accuracy and importance of the results.
· Therapeutic Decision Making
· Describe factors that frequently alter the effects of medications, including drug interactions and compliance problems.
· Formulate an initial therapeutic plan.
· Access and utilize, when appropriate, information resources to help develop an appropriate and timely therapeutic plan.
· Write prescriptions accurately.
· Monitor response to therapy.
Seminar discussion of theoretical issues
1. Anemia, definition, aetiology & pathogenesis.
2. Classification of anemia: pathogenetic classification, morphogenetic classification, international classification.
3. Clinical manifestations of anemia: anemic syndrome, sideropenic syndrome, neurologic manifestations, gastrointestinal manifestations, cytopenic syndrome, hemolytic syndrome.
4. Clinical manifestations of iron- deficiency anemia, clinical and laboratory and instrumental signs and treatment of iron- deficiency anemia.
5. Clinical manifestations of vitamin В12– deficiency anemia, clinical and laboratory and instrumental signs and treatment of folic acid – deficiency anemia.
6. Clinical manifestations of folic acid deficiency anemia, clinical and laboratory and instrumental signs and treatment of folic acid – deficiency anemia.
7. Clinical manifestations of aplastic anemia, clinical and laboratory and instrumental signs and treatment of aplastic anemia.
8. Classification, clinical manifestations of hemolytic anemia, clinical and laboratory and instrumental signs and treatment of hemolytic anemia.
Test evaluation and situational tasks.
Choose the correct answer/statement:
1. The most common cause of aplastic anemia is:
A. Idiopathic
B. Chloramphenicol
C. Phenylbutazone
D. Petroleum products
E. Prednisolone
2. Treatment of choice for aplastic anemia is:
A. Methotrexat
B. ampicillini
C. chloramphenicol
D. Bone marrow transplantation
E. plasmaphoresis
3. Most sensitive and specific test for diagnosis of iron deficiency is:
A. Serum ferritin levels
B. Serum iron levels
C. Serum transferrin receptor population
D. Transferrin saturation
E. Hb, Ht
4. Laboratory finding in anemia of chronic disease is
A. TIBC decreased
B. Serum iron decreased
C. Ferritin decreased
D. Hypoalbulinemia
E. Macrocytic anemia
5. Reduced serum iron and iron binding capacity is seen in:
A. Sideroblastic anemia
B. Thalassemia
C. Iron deficiency anemia
E. Hemolytic anemia
6. Following features may be present in patients of paroxysmal nocturnal haemoglobinuria except
A. Raised lactate dehydrogenase
B. Reticulocytjsis
C. High leucocyte alkaline phosphatase
D. Hemosiderinuria
E. Decreased RBC
7. Mucosal transfer of iron in GIT by
A. Transferrin
B. Apoferritin
C. Apotransferrin
D. Ferritin
E. Haptoglobin
8. Pernicious anemia is due to:
A. Iron deficiency
B. Chronic liver disease
C. Bleeding
D. Atrophic gastritis
E. Hemolysis
9. Spherocytosis is best diagnosed by:
A. Splenic puncture
B. BM aspiration
C. Plasma
D. Peripheral blood smear
E. Phenotyping
10. Coomb’s positive hemolytic anaemia is seen in:
A. Systemic lupus erythematosus
B. Thrombotic thrombocytopenic purpura
C. Scleroderma
D. Polyarteritis nodosa
E. Idiopathic thrombocytopenic purpura
Real-life situations to be solved:
1. Patient М, 52 year old, complains of weakness, dyspnea, numbness in extremities, subfebrile temperature and diarrhea. Objective: pale skin she has lemon-yellow hue, legs edema. Sternum is painful on percussion. Pulse – 100 per min, BP – 130/80 mmHg. Heart sounds weakened, systolic murmur at the apex. Smooth tongue. Liver +
2. Patient О., 35 year-old, mother of many children, complains of tiredness, palpitation, fragile nails, losing of hair. RBC- 2,3х1012/L, Нв -65g/L, CI – 0,7, reticulocytes – 0,5 %, Pletelets – 400 х109/L, WBC – 6,6 х109/L, band neutrophils – 2%, Segmented neutrophils – 56 %, basophils – 2%, lymphocytes – 29%, m – 10%, anisocytosis, poikilocytosis, ESR – 5 mm/h. What is the most likely diagnosis?
Initial level of knowledge and skills are checked by solving situational tasks for each topic, answers in test evaluations and constructive questions (the instructor has tests & situational tasks)
Students should know:
1. Erythropoesis and metabolism of iron in organism.
2. Methods of examination of patients with anemia.
3. Physiological and pathophysiological aspects of erythropoesis in anemia.
4. Correlation of red and white blood cells.
5. Megakaryocytic type of haemopoesis in fetus.
6. Evaluation of changes in peripheral blood smear.
7. Relevant terminology, definitions and classifications.
8. Chief complaints of patients with anemia (general signs, syndromes, anaemic syndrome).
9. Evaluation of basic signs and symptoms of anemia
10. Specific signs and symptoms in patients with anemia.
11. Methods of physical examination of patients with anemia.
12. Methods of laboratory evaluation of patients with anemia.
13. Methods of instrumental evaluation of patients with anemia.
14. Principles of management of patients with anemia.
15. Prescription of the appropriate therapy of anemia.
Students should be able to:
1. Perform a clinical exam of patients with anemia.
2. Reveal main clinical syndromes in patients with anemia.
3. Draft a plan of laboratory and instrumental evaluation of patients with anemia.
4. Assess the results of laboratory and instrumental evaluation in patients with anemia.
5. Diagnose the condition and formulate the diagnosis according to current classification of anemia.
6. Perform differential diagnosis of anemia.
7. Prescribe the appropriate therapy of anemia.
Correct answers of test evaluations and situational tasks:
Multiple Choice. 1 – A, 2 – D, 3-A, 4 – A, 5 – D, 6 – C, 7 – A, 8 – D, 9 – D, 10 – A
Real-life situations. 1. В12-deficiency anemia. 2. Iron deficiency anemia
References.
А – Basic:
1. Davidson’s Principles and practice of medicine (21st revised ed.) / by Colledge N.R., Walker B.R., and Ralston S.H., eds. – Churchill Livingstone, 2010. – 1376 p.
2.
3. The Merck Manual of Diagnosis and Therapy (nineteenth Edition)/ Robert Berkow, Andrew J. Fletcher and others. – published by Merck Research Laboratories, 2011.
4. Web -sites: www.tdmu.edu.ua: MANAGEMENT PATIENTS WITH ANEMIA
B – Additional:
1. Lawrence M. Tierney, Jr. et al: Current Medical Diagnosis and treatment 2000, Lange Medical Books, McGraw-Hill, Health Professions Division, 2000.
2. H.Loffler, J.Rastetter, T.Haferlach. 6th edition. Atlas of clinical hematology. Springer Berlin Heidelberg New York, 2006, – 429 p
3.
4. Web -sites:
a) http://emedicine.medscape.com/hematology anemia
b) http://meded.ucsd.edu/clinicalmed/introduction.htm
c) http://www.polconsultant.com/conteduc/hematology/anemia/index.htm
Methodical instruction has been worked out by assoc. prof. U.S.Slaba
Methodical instruction was discussed and adopted at the Department sitting “
Methodical instruction was discussed and adopted at the Department sitting “
Methodical instruction was discussed and adopted at the Department sitting “
Methodical instruction was discussed and adopted at the Department sitting “
