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METHODICAL INSTRUCTION FOR STUDENTS OF THE 6 COURSE

June 26, 2024

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 № 3 (PRACTICAL – 6 HOURS)

Theme 26: Management of patients with lymphadenopathy

Aim: to develop skills and to acquire experience relevant to management of patients with of leukaemia

Professional orientation of students. Lymphadenopathy can occur in any age group, in symptomatic or asymptomatic patients, and in a single site or at multiple sites. Lymphadenopathy is associated with numerous disorders. An abnormal lymph node may be observed or palpated by the patient, found by a health care worker, or discovered through radiologic evaluation. Lymphadenopathy may be a part of a complex case presentation, or the clinical cause may be straightforward. Patients with potentially curable malignant disorders may have lymphadenopathy as the first sign of their disease. This review of lymphadenopathy summarizes general considerations, discusses which patients might be considered for biopsy, reviews which nodes are most likely to be diagnostic, outlines initial diagnostic considerations on a region-by-region basis, and reviews a broad differential diagnosis for adenopathy.

Chronic lymphoid leukaemia is a most widespread form of lymphoproliferative tumour, peculiarity of which is slow barely visible development with accumulation of lymphocytes mass and gradual forcing out of other haemopoetic sprouts, increasing features of immunodeficiency, which frequently bring about the rising of infectious complications which can cause the premature patients death. That’s why understanding of these processes, diagnostics made in time and proper treatment-and-prophylactic measures can prevent early complications warning and for a long time continue active life of patients. The National Cancer Institute estimates 8,190 new cases and 1,070 deaths from Hodgkin disease in 2007. The age-adjusted incidence is 2.7 cases per 100,000 individuals. Hodgkin disease had a worldwide incidence of 62,000 cases in 2002.

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. Approaches to patients with lymphadenopathy

2. Algorithm of evaluation of lymphadenopathy

3. Classification of lymphopliferative diseases.

4. Classification of myelopliferative diseases.

5. Criteria for diagnosis of acute and chronic leukaemia.

6. Classification and stages of acute and chronic leukaemia.

7. Laboratory methods of investigation for diagnosis of diseases with lymphadenopathy.

8. Differential diagnosis of diseases with lymphadenopathy (hemoblastosis, infectious diseases (including HIV infection), tumour, systemic diseasis.

9. Management of the acute and chronic leukemia (principles, stage, complications of treatment, treatment of the different variety of the leukemias, symptomatic treatment).

Test evaluation and situational tasks.

Choose the correct answer/statement:

1. What is the reason thought to be the cause of complications in patient with chronic myelocytic leukemia?

A. Cerebral ishemia

B. Gum bleeding

C. High white cells count

D. Hypertension

E. Leukemic infiltration of organs

2. What genetic sign indicates on chronic myelogenous leukemia

A. No sings

B. XXX or XXY combination

C. Philadelphia chromosome in abnormal cells

D. chromosomes in the 19-st pare

E. Lack of chromosome 13 pare

3. What are the main laboratory findings in patient with chronic lymphatic leukemia?

A. Thrombocytosis

B. Thrombocytosis and lymphocytosis

C. Lymphopenia

D. Anemia and thrombocytopenia

E. Philadelphia chromosome in abnormal cells

4. Which drug is mostly used for the treatment of chronic lymphatic leukemia?

A. Prednisone

B. Chlorambucil

C. Methotrexate

D. Myleran

E. Ampicilin

5. What is the Acute Lymphatic Leukemia?

A. Disorder of the blood-forming tissue (white cells)

B. Disorder of the blood-forming tissue (red cells)

C. Leukocytosis

D. Increasing of blood pressure

E. Decreasing of blood pressure

6. What is a possible level of platelets in the patient with Acute Lymphoblastic Leukemia?

A. 100.000 – 150.000/L

B. Over 200.000/L

C. 150.000– 200.000/L

D. Below 100.000/L

E. Absence of Pl

7. What are the chief laboratory findings in patient with chronic lymphatic leukemia?

A. Thrombocytosis

B. Thrombocytosis and lymphocytosis

C. Lymphocytosis

D. No specific findings

E. Philadelphia chromosome in abnormal cells

8. In which patients with chronic myelogenous leukemia the intracerebral hemorrhage occurs more frequently?

A. With high white cells counts (over 300 x 10¹²/L)

B. With low white cells counts

C. With no changes

D. Increased level of erythrocytes

E. Anemia

9. Bone marrow transplant is the treatment of choice in all, except:

A. Aplastic anemia

B. AML in 1st remission

C. ALL in second remission

D. ITP

E. Lympoma

10. Acute leukaemic phase is not seen in :

A. CLL

B. AML

C. Blast crisis CML

D. Hodgkin’s lymphoma

E. AML, Blast crisis CML

Real-life situations to be solved:

1. The patient, 18-years-old was admitted to the hospital with complaints of headache, weakness, high temperature, pain in the throat. Objectively: enlargement of all groups of lymphatic nodules was revealed. The liver is enlarged by 3 cm, spleen – by 1 cm. CBC analysis shows leukocytosis, lymphocytosis. What is the probable diagnosis?

2. A 68-year-old man complains of tiredness, sweating, enlargement of cervical, submandibular and axillary lymph nodes. Blood tests: WBC – 35 x 10⁹/L, lymphocytes – 60%, smudge cells, level of hemoglobin and quantity of thrombocytes are normal. Myelogram showes 40% of lymphocytes. What is the most probable 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. Scheme of leukocytes maturing.

2. Correlation of red and white sprout, level of blasts in myelogram.

3. Methods of determination of leukocytes and platelets in peripheral blood.

4. Leukocyte Differential Count

5. Status of haemopoetic system in a norm and at pathology.

6. Scheme and mechanisms of haemopoesis, especially myelopoesis.

7. Substances and consequence of controlled myeloproliferation.

8. Anatomy and histology of hemopoetic lymphoid organs (bone marrow, spleen, liver, lymph nodes).

9. Functional characteristic of the peripheral blood cells.

10. Investigation methods of the patients with blood diseases.

11. Criteria for the following syndromes: anemic, hemorrhagic, intoxication, hyperplastic, immunodeficiency syndromes.

12. Routine blood analysis and its interpretation.

13. Scheme and mechanisms of haemopoesis, especially of lymphopoesis.

14. Substances and consequences of uncontrolled lymphoid proliferation.

Students should be able to:

1. Perform a clinical exam of patients with lymphadenopathy.

2. Reveal main clinical syndromes in patients with lymphadenopathy.

3. Draft a plan of laboratory and instrumental evaluation of patients with lymphadenopathy.

4. Evaluation of the results of laboratory and instrumental investigation in patients with lymphadenopathy.

5. Diagnose the condition and formulate the diagnosis according to current classification of leukemia.

6. Perform differential diagnosis of lymphadenopathy.

7. Prescribe the appropriate therapy of leukemia.

Correct answers of test evaluations and situational tasks:

Multiple Choice. 1 – A, 2 – C, 3-D,4 – B,5 – A, 6 – A, 7 – C, 8 – A, 9 – D, 10 – A

Real-life situations. 1. Infectious mononucleosis. 2. Chronic lymphocytic leukemia

References.

А – Basic:

1. Davidson’s Principles and practice of medicine (21^st revised ed.) / 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^th edition) / 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, Andrew J. Fletcher and others. – published by Merck Research Laboratories, 2011.

4. Web -sites: www.tdmu.edu.ua: MANAGEMENT OF PATIENTS WITH LYMPHADENOPATHY

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. 6^th edition. Atlas of clinical hematology. Springer Berlin Heidelberg New York, 2006, – 429 p

3. Oxford Handbook of Clinical Haematology (3 ed.), Drew Provan, Charles R J Singer, Trevor Baglin, and Inderjeet Dokal

4. Web -sites:

a) http://emedicine.medscape.com/hematology anemia