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 2. Principles of diagnosis, management and prevention of main musculoskeletal disorders
LESSON № 1 (PRACTICAL – 6 HOURS)
Theme 12. Main symptoms and syndromes in rheumatology. Ankylosing spondylitis.
Aim: to develop skills and to acquire experience relevant to management of patients withmain rheumatological symptoms and syndromes. Learn diagnosing and treatment of Ankylosing spondylitis (AS).
Professional orientation of students. Rheumatic diseases are extremely widening. From 1 % to 3 % of people in Europe and America suffer from some form of the joint disease. Arthritis can be present in the number of specifically identifiable conditions exceeds 100, that cause pain in the joints and connective tissues. It is necessary performing the differential diagnosis of arthritis, because joint symptoms present not only in inflammatory arthritis, degenerative joint disease, but may be part of a systemic disease. If you can make a diagnosis early in your patient you may be able to forestall, reduce or even prevent entirely some of the more severe or debilitating complications seen with those disorders. Ankylosing spondylitis most often begins between ages 20 and 40, but it may begin earlier. Three males are diagnosed with AS for every one female; the overall prevalence is 0.25%.
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. Etiology and pathophysiology issues of AS.
2. Classification of AS.
3. Main clinical findings of AS.
4. Main laboratory and instrumental findings of AS.
5. Management strategies: principles of choice of the right strategy of AS.
6. Drug therapy: indications and contraindications of AS.
Test evaluation and situational tasks.
10 multiple choice tests
Multiple Choice Questions
Choose the correct answer/statement
1. A 30-yr-old man presents with a 10-yr history of back pain, worse in the morning and one episode of iritis. Choose the most likely diagnosis from the below list of options.
A. Ankylosing spondylitis
B. Reactive arthritis
C. Osteoarthritis
D. Gout
E. Psoriatic arthritis
2. In what disease squaring of vertebra gives ‘bamboo spine’ appearance?
A. Ankylosing spondylitis
B. Reactive arthritis
C. Osteoarthritis
D. Gout
E. Psoriatic arthritis
3. A 20-yr-old man presents with morning stiffness, sacroiliitis and iritis. Choose the most likely diagnosis from the below list of options.
A. Haemochromatosis
B. Ankylosing spondylitis
C. Gonococcal arthritis
D. Reiter’s syndrome.
E. Psoriatic arthropathy
4. The presence of which one of the following is helpful in the diagnosis of ankylosing spondylitis?
A. Serum antinuclear antibodies
B. Rheumatoid factor in the serum
C. HLA-B27
D. Female gender
E. HLA-B8
5. Serological findings in patients with systemic lupus erythematosus (SLE) will NOT include which one of the following:
A. A raised serum IgG level
B. Antibodies to double-stranded DNA
C. Decreased C3 and C4 levels
D. A ‘positive’ VDRL
E. Antibodies to cyclic citrullinated peptide (anti-CCP antibodies)
6. Which one of the following statements about autoimmune connective tissue diseases?
A. Affect about 1 person in every 1000.
B. Are more common in women
C. Tend to begin in early childhood.
D. Are an inevitable consequence of autoimmune responses.
E. They are consequence of infections
7. A 33-yr-old man presents with a 8-yr history of back pain, worse in the morning, limitation of movement of spine. Choose the most likely diagnosis from the below list of options.
A. Psoriatic arthritis
B. Joint sepsis
C. Ankylosing spondylitis
D. Reactive arthritis
E. Rheumatoid arthritis
8. A condition that affects males more than females, which starts with inflammatory joint symptoms in late teens or early twenties. There is a gradual improvement in symptoms in later life. Choose the most likely diagnosis from the below list of options.
A. Ankylosing spondylitis
B. Psoriatic arthritis
C. Joint sepsis
D. Reactive arthritis
E. Rheumatoid arthritis
9. A 24-yr-old brick layer with ankylosing spondylitis has increasing early morning stiffness and back pain. He is oo medication at present. Choose the most likely management from the below list of options.
A. Colchicine
B. Oral NSAIDs
C. Prednisolon
D. Paracetamol
E. Allopurinol
10. X-ray findings in systemic lupus polyarthritis are:
A. ankylosis;
B. cartilage loss;
C. erosions;
D. osteophytes;
E. no destructions.
Real-life situations to be solved:
2 real-life situation to be solved
1. A 26-year-old man has had progressive, active ankylosing spondylitis for 6 years that has been refractory to maximal doses of nonsteroidal anti-inflammatory drugs, sulfasalazine, and more recently, methotrexate (12.5 mg/week). He has severe pains around the insertion points of tendon into bone around his knees, ankles, and heels. On physical examination, his neck is very painful, with limited rotation. His upward gaze is limited to the horizon. On administration of the Schober test, points move from 10 to 11 cm. Although the patient has only slight joint effusions, there is marked tenderness at the insertions of quadriceps and lower leg extensor muscles, and at the insertion of the Achilles tendon into the calcaneus bilaterally. He has a mild anemia and a C-reactive protein level of 3.2 mg/dL. Evaluation by power Doppler sonography shows that he has very active enthesitis at the knees, ankles, and feet, especially the heels. Which management is most appropriate at this time?
2. A condition that affects males more than females, which starts with inflammatory joint symptoms in late teens or early twenties. There is a gradual improvement in symptoms in later life. 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. Normal values for CBC, blood chemistry, urin alysis, immunologic tests.
2. Specific immunological tests for rheumatologic diseases.
3. XR-diagnostics of joints and spine iormal and degenerative and inflammatory diseases.
4. Determination artralgic syndrome, systemic inflammatory response syndrome.
5. General muscle-skeletal anatomy and physiology.
6. Relevant terminology, definitions and classifications of AS.
7. Chief complaints of AS.
8. Evaluation of basic signs and symptoms of AS.
9. Specific signs and symptoms of AS.
10. Methods of physical examination of AS.
11. Methods of laboratory evaluation of AS.
12. Methods of instrumental evaluation of AS.
13. Principles of management of AS.
Students should be able to:
Interpret the data in CBC, blood chemistry, urinalysis, immunologic tests.
1. Interpret specific immunological tests for rheumatologic diseases.
2. Interpret radiological images for diseases of joints and spine iormal and degenerative and inflammatory diseases.
3. Determine artralgic syndrome, systemic inflammatory response syndrome.
4. Perform a clinical exam of AS.
5. Reveal main clinical syndromes of AS.
6. Draft a plan of laboratory and instrumental evaluation of AS.
7. Assess the results of laboratory and instrumental evaluation of AS.
8. Diagnose the condition and formulate the diagnosis according to current classification of AS.
9. Perform differential diagnosis of AS.
10. Prescribe the appropriate therapy of AS.
Correct answers of test evaluations and situational tasks:
Multiple Choice Questions 1-A, 2-A, 3-B, 4-C, 5- E, 6-B,7- C, 8-B, 9-B, 10-E.
Real-life situations.
The correct answer is
1. Add a tumor necrosis factor-α inhibitor to the methotrexate and sulfasalazine.
2. Ankylosing spondylitis.
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:
a)http://intranet.tdmu.edu.ua: Main symptoms and syndromes in rheumatology
d)http://emedicine.medscape.com/
e)http://meded.ucsd.edu/clinicalmed/introduction.htm
B-Additional
1. Clinical Rheumatology (The Clinical Medicine Series) 12 edition/ Pacific Primary Care Software PC/ M.D., C. G. Weber.- 2011.-p.526 .
2.Kelley’s Textbook of Rheumatology, 9th Revised edition / Firestein, Gary S.; Budd, Ralph C.; Gabriel, Sherine E.; O’Dell, James R.; McInnes, Iain B.-2012.-p. 2292.
3. Spondyloarthropathies, an Issue of Rheumatic Disease Clinics / Braun, Juergen; Sieper, Joachim. – 2012.- p.240.
4. Best Practice & Research: Clinical Rheumatology / Anthony Woolf . Volume 4.- 2010.[http://ees.elsevier.com/berh]
Methodical instruction was been worked out by: Prof. S.I.Smiyan “
Methodical instruction was adopted and reviewed at the Department sitting 15.06.2009, Minute № 2
Methodical instruction was adopted and reviewed 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
