METHODICAL INSTRUCTION FOR STUDENTS OF THE 6 COURSE

foreign students’ Faculty

Module 3. CURRENT PRACTICE OF INTERNAL MEDICINE

Content module 3. Management of patients with disorders of gastrointestinal tract, liver and pancreatic diseases

LESSON № 3 (PRACTICAL – 6 HOURS)

 

Theme 13. Management of patients with hepatolienal syndrome. Management of patients with portal hypertension. Management of patients with ascites

 

Aim: – to develop skills and to acquire experience relevant to management of patients with hepatolienal syndrome, portal hypertension, ascites

Professional orientation of students. Chronic hepatic pathology is one of the acute problems of the modern gastroenterology. Patients with chronic hepatitis have the high risk to passing this pathology in hepatic cirrhosis and hepatocellular carcinoma. About three hundred thousand people die from liver cirrhosis every year. Each year frequency of cirrhosis increases. That is why we must learn early diagnostics and basic treatment of these diseases.

 

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.     Anatomy and physiology of liver cirrhosis.

2.     Clinical manifestations of liver cirrhosis.

3.     History taking and physical examination of the patients with liver cirrhosis.

4.     Methods of examination of patients with liver cirrhosis.

5.     Laboratory diagnostics of liver cirrhosis.

6.     Instrumental diagnostics of liver cirrhosis

7.     Differential diagnostics of hepatolienal syndrome.

8.     Clinical classification of liver cirrhosis.

9.     Complications of liver cirrhosis.

10. Principles of treatment of liver cirrhosis.

11. Treatment of complications of liver cirrhosis.

12. Prophylaxis of liver cirrhosis.

Test evaluation and situational tasks.

 

Choose the correct answer/statement:

1. A 57-yr-old man has a history of recurrent ascites, which is exudative iature. On abdominal paracentesis numerous neutrophils are found in the ascitic fluid. choose the single most likely diagnosis from the list of options above.

A.Carcinomatous peritonei    

B.Budd-Chiari syndrome       

C.Liver cirrhosis                     

D.Nephrotic syndrome                                                    

E.Hepatocellular carcinoma

2. A healthy young waiter complains of feeling unwell with nausea, vomiting and diarrhoea. He has a headache, fever and abdominal pain. On palpation you find the liver to be tender and enlarged. choose the single most likely diagnosis from the list of options above.

A. Hepatitis A

B. Hepatitis B

C. Hepatitis C

D. Gallstones

E. Pancreatitis

3. Which morphologic changes  differ alcoholic hepatitis from viral:

A. hepatocytes with sandy nuclei

B. hepatocytes with  corpuscules Mallory

C. acidophilus degeneration of hepatocytes

D. Kaunsilmen’s corpuscules  

E.  mat hepatocytes .

4. The radiographic hallmark of chronic pancreatitis is:

A.   the presence of scattered calcification throughout the pancreas

B.   enlargement of pancreas

C.   the presence of ductal decompression

D.   inflammation of the pancreas

E.    replacement of the pancreas

5.Pancreatic calcification may be seen in the following cases except:

A.   primary diabetes mellitus

B.   severe protein-calorie malnutrition,

C.   hereditary pancreatitis,

D.   posttraumatic pancreatitis,

E.    hyperparathyroidism

6.What is the only major technique that provides a direct view of the pancreatic duct?

A.   Endoscopic retrograde cholangiopancreatography

B.   Sonography

C.   CT

D.   Plain radiography

E.    Laparoscopy.

7.Ultrasonography can provide important information in patients with all of the following except:

A.   perforated duodenal ulcer

B.   acute pancreatitis,

C.   chronic pancreatitis,

D.   pancreatic calcification,

E.    pseudocyst.

8.In acute pancreatitis, the pancreas:

A.   is characteristically enlarged

B.   has scattered calcification

C.   has ductal decompression

D.   is replaced

E.    no changes

9.Most lesions of pancreas on CT are characterized by all of the following except:

A.   the presence of ductal decompression

B.   enlargement of the pancreatic outline,

C.   distortion of the pancreatic contoura

D.   a fluid filling that has a different attenuation coefficient thaormal pancreas

E.    none of the listed

10.   The differential diagnosis of chronic pancreatitis should include all of the following disorders except:

A.   paroxysmal atrium fibrillatium

B.   perforated peptic ulcer;

C.   acute cholecystitis and biliary colic;

D.   acute intestinal obstruction;

E.    mesenteric vascular occlusion.

 

Real-life situations to be solved:

1.Patient L, 52 years old, during last 18 years suffers from mitral stenosis. Since last 7 weeks patient has complained on feeling of discomfort in the area of heart; pain and feeling of discomfort in right subcostal area; flatulence, nausea. Objectively: a skin is icteric, peripherial cyanosis, peripherial edema; ascites; a liver at palpation is increased, dense, an edge is sharp, Plesh’s symptom is negative; splenomegaly. The markers of viral infection are absent. On the appointed therapy a liver is irresponsive. Formulate a previous diagnosis. 

2. Patient 48 years, complains on vomiting with blood, discomfort in right subcostal area, absence of appetite, weakness. Abuses an alcohol. Objectively: decreased nourishment, yellowish of scleras, skin, vascular “stars” on the skin, expansion of veins on front abdominal wall. A liver is increased on 5 sm,  spleen – on 4 sm. What is the reason of bleeding?

 

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. General anatomy and physiology  of digestive system

2. Relevant terminology, definitions and classifications of  liver diseases

3. Chief complaints of patients with pathology of liver diseases

4. Evaluation of basic signs and symptoms in patients with pathology of liver diseases

5. Specific signs and symptoms of patients with pathology of liver diseases

6. Methods of physical examination of patients with pathology of liver diseases

7. Methods of laboratory evaluation of patients with pathology of liver diseases

8. Methods of instrumental evaluation of patients with pathology of liver diseases

9. Principles of management of patients with pathology of liver diseases

Students should be able to:

1. Perform a clinical exam of patients with pathology of  liver diseases

 2. Reveal main clinical syndromes of patients with pathology of liver diseases

3. Draft a plan of laboratory and instrumental evaluation of patients with pathology of liver diseases

4. Assess the results of laboratory and instrumental evaluation of patients with pathology of liver diseases

5. Diagnose the condition and formulate the diagnosis according to current classification of patients with pathology of liver diseases

6. Perform differential diagnosis of pathology of liver diseases

7. Prescribe the appropriate therapy for the patients with pathology of  liver diseases

 

Correct answers of test evaluations and situational tasks:

Multiple Choice. 1 – C. 2 – A. 3-C.4-A.5-A.6-A.7-A.8-A.9-A.

Real-life situations. 1. Cardiac cirrhosis of liver.  2. Bleeding from the esophagogastric varices.

 

References:

A – Basic:

1.                 Davidson’s Principles and Practice of Medicine / Edited by  Nicki R. Colledge,    Brian R. Walker ,   Stuart H. Ralston, 1st Edition. – – Philadelphia : Churchill Livingstone, 2010. – 1376 p.

2. Harrison‘s Principles of Internal Medicine. Dan L.Longo M.D. – New York : McGraw-Hill, 2012. – 4012 p.

3. Harrisons Principles of Internal Medicine Self-Assessment and Board Review /  Charles M. WienerAnthony

   S. Fauci , Eugene Braunwald, Dennis L. Kasper, Stephen L. Hauser, Dan L. Longo, J.Larry Jameson, Joseph Loscalzo, Cynthia Brown, 18th Revised edition. – New York : McGraw-Hill Education – Europe, 2012. – 512 p.

4. The Merck Manual of Diagnosis and Therapy / Edited by Robert S. Porter.,  19th Revised edition. –  London : Elsevier Health Sciences, 2011. – 3754 p.

5.                 Kumar and Clark’s Clinical Medicine (With STUDENTCONSULT Online Access) / Edited by Parveen Kumar, Michael L. Clark,  8th Revised edition. – London : Elsevier Health Sciences, 2012. – 1304 p.

6.                 Web–sites:  www.tdmu.edu.ua : MANAGEMENT OF PATIENT WITH HEPATOLIENAL SYNDROME

 

B – Additional:

1.Textbook of Clinical Gastroenterology and Hepatology (2nd Revised edition) /

Edited by C. J. Hawkey, Jaime Bosch, Joel E. Richter, Guadalupe Garcia-Tsao, Francis K. L. Chan. – Chicester : John Wiley and Sons Ltd, 2012. – 1272 p.

2. Oxford Handbook of Gastroenterology and Hepatology (2nd Revised edition). Stuart Bloom, George Webster, Daniel Marks. – Oxford : Oxford University Press, 2012. – 648 p.

3. Harrison‘s Gastroenterology and Hepatology (1th edition). Dan L. Longo, Anthony S. Fauci. – New York :  McGraw-Hill Education – Europe, 2010. – 752p.

4. Mayo Clinic Gastroenterology and Hepatology Board Review (4th Revised edition).  Stephen Hauser.  – Oxford : Oxford University Press Inc., 2011.  – 480 p

5.Web-sites:

 http://emedicine.medscape.com/gastroenterology 

 

Methodical instruction has been worked out by:  assos. prof. G.V.Lykhatska

Methodical instruction was discussed and adopted at the Department sitting 29.06.2010, Minute № 19 

 Methodical instruction was adopted and reviewed at the Department sitting 16.06.2011, Minute № 13

 Methodical instruction was adopted and reviewed at the Department sitting 12.06.2012, Minute № 12

 Methodical instruction was adopted and reviewed at the Department sitting 25.06.2013, Minute № 17