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METHODOLOGICAL INSTRUCTION:

June 18, 2024

METHODICAL INSTRUCTION FOR STUDENTS OF THE 5 COURSE

foreign students’ Faculty

MODULE 2. PRINCIPLES OF INTERNAL MEDICINE

(cardiology, rheumatology, nephrology, common questions of internal medicine)

Content module 3. “Principles of diagnosis, management and prevention of main kidney and urinary tract diseases”

LESSON № 1 (PRACTICAL – 6 HOURS)

Theme 18. Main symptoms and syndromes in nephrology

Aim: studying of the clinical methods of examination and laboratory and instrumental examination of the patients with kidney pathology.

Professional orientation of students. There is clearly defined trend of increasing of kidney disease in all age gradations over the last decade in all countries, including Ukraine. That is why timely diagnosis of these forms of pathology significantly solves the problem of their successful treatment. It was developed new, highly informative methods of laboratory and instrumental diagnostics of renal diseases, enabling diagnosis of these forms of pathology at early stages of development, which is key to their successful treatment. Specific characteristics inherent to the clinical examination of patients with suspected renal disease. Correct interpretation of the changes obtained in the study of blood, urine and urinary sediment (urinary, nephrotic syndrome) is required to justify further diagnostic work-up in order to clarify the causes of these changes, choosing the right medical tactics (outpatient, inpatient treatment), and assigning adequate treatment.

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) (for clinical department):

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. Main complaints and the main symptoms in patients with renal diseases.

2. General and specific symptoms of renal diseases.

3. Physical symptoms of renal pathology.

4. Methods of physical examination.

5. Interpretation of urinalysis, microscopic examination of urinary sediment.

6. Quantification of the cellular composition of urine, interpretation of bacteriological examination of urine in patients with renal diseases.

7. Interpretation of the complete blood count in patients with renal diseases.

8. Investigation of renal function by laboratory methods (glomerular filtration rate, tubular concentration function (test for Zimnitskiy), nitrogen excretory renal function and electrolyte metabolism)

9. Roentgenologic methods of kidney examination.

10. Interpretation of renal ultrasonography.

Test evaluation and situational tasks.

Choose the correct answer/statement:

1. Histologic changes shown to correspond to worsening GFR in CKD include all of the following EXCEPT:

A. Decreased number of peritubular capillaries

B. Severity of glomerular injury

C. Intensity of interstitial inflammation

D. Increased interstitial volume and fibrosis

E. None of above

2. Choose the leading mechanism for urine concentrating:

A. Active reabsorption of Na in the ascending loop of Henle;

B. Active transport of urea by cells of ascending loop of Henle

C. The impact of antidiuretic hormone on the loop of Henle

D. Повышение проницаемости

E. Active transport of water in the distal nephron

3. Brush border in a nephron in the:

A. The proximal tubule

B. The loop of Henle

C. The distal convoluted tubule

D. Communications division

E. The collecting tube

4. The mechanisms of proteinuria are all of the following except?

A. Overflow of elevated normal or abnormal serum proteins

B. Decreased reabsorption of normal filtered proteins

C. Increased glomerular permeability

D. Changes in renal hemodyndamics

E. Hypercoagubility

5. Potassium excretion in the urine is determined by the:

A. Glomerular filtration

B. Proximal potassium secretion

C. Distal reabsorption of potassium

D. Proximal reabsorption of potassium

E. Distal potassium secretion

6. Which drugs should not be used in pregnancy.

A. Fluoroquinolones;

B. Phospomycine;

C. Aminoglucosides;

D. Macrolydes;

E. amoxicillin

7. Which of the following factors lead to the cessation of glomerular filtration is:

A. Increasing the hydrostatic pressure in the capsule of Bowman to 15 mm Hg

B. The increase of oncotic pressure of 40 mm Hg in plasma

C. The increase of renal blood flow to 600 ml / min

D. Reduction of systolic pressure up to 60 mm Hg

E. None of above

8. The man, 45 years old, has the following parameters: body weight 62 kg,proteinuria – 1.4 g / l, serum creatinine – 205 mmol/l, sodium serum – 138 mmol/L, daily diuresis 1500 ml. Glomerular filtration rate is:

A. 12 ml/min

B. 35 ml/min

C. 60 ml/min

D. 100 ml/min

E. 298 ml/min

9. The nephritic syndrome is a clinical complex characterized by a number of renal and extrarenal features, the most prominent of which are:

A. Proteinuria of > 3.5 g (per 24h);

B. hypoalbuminemia;

C. edema;

D. hyperlipidemia;

E. allofthem.

10. Which statement regarding orthostatic proteinuria is incorrect?

A. Proteinuria is absent in the horizontal position of the patient

B. There is persistent proteinuria in a small number of patients over time,

C. Renal failure develops in most patients

D. Daily proteinuria greater than 1 g

E. All are correct

Real-life situations to be solved:

2 real-life situation to be solved

1. A 30-year–old woman complains of dysuria, fever, shaking chills, nausea, vomiting, and diarrhea, generalized muscle tenderness. Physical examination reveals tachycardia, marked tenderness on deep pressure in both costovertebral angles and on deep abdominal palpation. What kind of examination will show changes and what changes will you expect to see?

2. The patient after acute respiratory viral infection [10^th day of disease] has complaints on headache, oliguria, cola–colour urine. Urinalysis – hematuria [100-200 RBC in eye shot spot], specific gravity – 1002. The blood creatinin level is 0,18mmol/l, potassium level – 5,4 mmol/l. Select a leading syndrome. Make the previous 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. Anatomy and physiology of the kidneys.

2. Normal quantities of the main clinic and biochemical homeostasis.

3. Pathogenensis of the main clinical manifestations of the renal diseases.

4. General and specific syndromes occur in patients with renal diseases.

5. The main laboratory and instrumental investigations inpatients suffering from renal diseases.

Students should be able to:

1. To collect complaints, anamnesis data

2. To make physical examination the patients with renal diseases.

3. To interpret clinical, laboratory and instrumental investigation in patients withrenal diseases.

4. To find clinical and laboratory-instrumental syndromes in patients with renal diseases.

Correct answers of test evaluations and situational tasks:

Multiple Choice Questions: 1 – B; 2 – A; 3 – A; 4 – E; 5– D; 6– A; 7 – D; 8 – B; 9 – A; 10 – C.

Real-life situations. The correct answers are:

1.The routing urine analysis. Microscopic examination of urine reveals numerous pus cells and organisms, some red cells and epithelial cells. Pyuria and low level proteinuria are common for chronic pyelonephritis, but not invariable.

2.Nephritic syndrome. Acute glomerulonephritis, nephritic syndrome

References:

А – Basic:

1. Davidson’s Principles and practice of medicine (21^streviseded.)/by Colledge N.R., Walker B.R., and Ralston S.H., eds.–Churchill Livingstone, 2010.–1376 p.

2. Harrison’s principles of internal medicine (18^thedition)/by Longo D.L., Kasper D.L., Jameson J.L. et al .(eds.). – McGraw–Hill Professional, 2012. – 4012 p.

3. The Merck Manual of Diagnosis and Therapy (nineteenth Edition)/Robert Berkow, AndrewJ. Fletcher and others. –published by Merck Research Laboratories, 2011.