METHODICAL INSTRUCTION FOR STUDENTS OF THE 6 COURSE
foreign students’ Faculty
Module 3. Current practice in internal medicine
Content module 2. «Management of patients with musculoskeletal disorders»
LESSON № 1 (PRACTICAL – 6 HOURS)
Theme7. Management of patients with arthritic syndrome.
Aim: – to develop skills and to acquire experience relevant to management of patients with arthritic syndrome, in particular those : Rheumatoid arthritis (RA), Osteoarthritis (OA), Gouty arthritis (GA), Ankylosing Spondylitis (AS), Reactive Arthritis (ReA), Psoriatic Arthritis (PsA).
Professional orientation of students. rheumatological diseases remains the major cause of morbidity and mortality throughout the developed world and it is also rapidly increasing in the developing world. Fortunately, increased scientific inquiry is contributing to a better understanding ofarthritic syndrome, its contribution to numerous disease processes, and more treatment options for these patients.
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.
2. Classification
3. Main clinical findings
4. Main laboratory and instrumental findings
5. Management strategies: principles of choice of the right strategy
6. Drug therapy: indications and contraindications
Test evaluation and situational tasks.
Multiple Choice Questions
Choose the correct answer/statement
1. 73-year-old male with foot pain and swelling for many years. There are “punched out” articular erosions with overhanging cortex and associated soft tissue masses consistent with tophaceous gout and gouty arthritis. Choose the most likely changes from the below list of options.
A. Urate crystals on joint aspirate
B. High ESR
C. Erosions on X-ray
D. Positive blood culture
E. Positive rheumatoid factor
2. 79 y/o female with foot pain and swelling for many years. There are “punched out” articular erosions with overhanging cortex and associated soft tissue masses. Serum uric acid was markedly elevated. Choose the most likely diagnosis from the below list of options.
A. Ankylosing spondylitis
B. Rheumatoid arthritis
C. Osteoarthritis
D. Chronic Gouty arthritis
E. Psoriatic arthritis
3. 86 year old male with chronic gout presents with bilateral foot pain. Physician desired radiograph for evaluation of extent of pathologic changes. Prominent erosive destruction of bilateral first metatarsals and second distal phalanx with well-preserved joint spaces throughout. Choose the most likely changes from the below list of options.
A. High ESR
B. Oseoporosis on X-ray
C. Positive blood culture
D. Urate crystals on joint aspirate
E. Positive rheumatoid factor
4. A 25-yr-old man presents with a 10-yr history of back pain, worse in the morning and one episode of iritis. Choose the medications from the below list of options.
A. Methotrexate
B. Actovegin
C. Mydocalm
D. Warfarin
5. A 50-yr-old woman complains of stiffness in her fingers worse at the end of the day. The DIP joints and the first metacarpophalangeal joints are affected. Choose the most likely diagnosis from the below list of options.
A. Osteoarthritis
B. Rheumatoid arthritis
C. Psoriatic arthropathy
D. Haemochromatosis
E. Gonococcal arthritis
6. A 57-year-old woman has had five episodes of joint pain and swelling, lasting 3 to 8 days, involving the right knee and left elbow. She is asymptomatic between attacks, and sulindac, 200 mg twice daily, has usually relieved the symptoms. Her most recent episode was 4 months ago. Classical picture of exacerbation of the arthritis includes all of the following except
A. Excruciating and sudden pain
B. Low-grade fever may also be present
C. Overgrowth at the distal interphalangeal joints
D. Warmness
E. Redness
7. A 60-yr-old alcoholic man presents with a hot swollen first metatarsophalangeal joint and a lesion on the rim of the left pinna. Choose the investigation for diagnosis from the below list of options.{
A. HLA-B27
B. Synovial fluid analysis
C. X-ray
D. Anti-dsDNA antibody
E. Rheumatoid factor
8. A 63-year-old man is evaluated because of a 2-year history of bilateral knee pain and low back pain. He has some stiffness for approximately 15 minutes when she awakens in the morning, and during the afternoon her pain is worse. On physical examination, he has slight swelling and tenderness to pressure of the distal interphalangeal joints 2-5 on both hands. There is slight crepitus with motion of the right knee. Which of the following treatment do use?{
A. Methotrexat
B. Colchicines
C. Chondroitin sulfate
D. Tetracycline
E. Allopurinol
9. A 65-year-old man comes to your office complaining of knee pain that began insidiously about a year ago. He has no other rheumatic symptoms. Which of the following signs isn’t sign of the arthritis?{
A. Pain is related to use
B. Pain gets worse during the day
C. Minimal morning stiffness (<20 min) and after inactivity (gelling)
D. Warmth of skin over effected joints
E. Range of motion decreases
10. A 68-year-old man presents with an acutely red and swollen right great toe without history of trauma. Which of the following findings is most useful for making a diagnosis of gout in this patient?{
A. Persistent elevation of serum uric acid
B. Good response to colchicines trial
C. Radiograph showing marginal joint erosion in the first metatarso-phalangeal (MTP) joint
D. An associated right ankle effusion
E. A painless elbow nodule
Real-life situations to be solved:
1. A 38-year-old woman presents with a 23-month history of morning stiffness, pain, and swelling in her hands and wrists. She has noticed general fatigue, and the hand stiffness lasts about an hour. Joints of all her extremities are involved symmetrically. The patient does not smoke or drink. On physical examination, her temperature is 38 В°C (100.4 В°F). Examination of the joints reveals thickening and tenderness of the metacarpo-phalangeal joints and proximal interphalangeal joints bilaterally. Both wrists lack complete flexion and extension and are warm to the touch. What is the most likely diagnosis? Prescribe treatment.
2. A 25year-old man presents because of a painful, swollen knee and ankle of 2 weeks’ duration. He has never had joint disease prior to this time. The patient also complains of low back pain and a recent history UTI. On examination he has vesicles (some of which have crusted over) on the palms, soles, and glans penis; injected conjunctivae; a swollen right index finger; and arthritis of the right knee and left ankle. What is the most likely diagnosis? Prescribe treatment.
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 musculo-sceletal anatomy and physiology.
2. Relevant terminology, definitions and classifications.
3. Chief complaints of rheumatological patients.
4. Evaluation of basic signs and symptoms
5. Specific signs and symptoms.
6. Methods of physical examination of rheumatological patients.
7. Methods of laboratory evaluation of rheumatological patients.
8. Methods of instrumental evaluation of rheumatological patients.
9. Principles of management.
Students should be able to:
1. Perform a clinical exam of rheumatological patients.
2. Reveal main clinical syndromes.
3. Draft a plan of laboratory and instrumental evaluation of rheumatological patients.
4. Assess the results of laboratory and instrumental evaluation.
5. Diagnose the condition and formulate the diagnosis according to current classification.
6. Perform differential diagnosis.
7. Prescribe the appropriate therapy.
Correct answers of test evaluations and situational tasks:
Multiple Choice Questions. 1 –A, 2 –A,3 – D, 4 –A, 5-C, 6-A, 7-B, 8-D, 9-C, 10-A.
The correct answer for real-life situations:
1. Rheumatoid arthritis. Prednisolon start from 90 mg i/v, then 20-30 mr per os, Cyclophosphamide 200 mg i/v – every other day till 1000 mg, thanMethotrexate 15 mg once a week. NSAID’s.
2. Reiter’s syndrome, consultation of urologist, urethra cytologie examination for findin chlamydies, proteins and its fractions, x-ray examination of the right knee and of the sacroiliac joints, synovial fluid aspiration with analysis of the synovial fluid. Antibiotics (Doxacycline, Tetracycline), NSAID’s.
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 : Management of patients with arthritic syndrome
c) http://emedicine.medscape.com/
d) 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. Early Arthritis, An Issue of Rheumatic Disease Clinics/Torralba, Karen; Quismorio, Francisco P.; Panush, Richard S.-2012. –p.90
4. Best Practice & Research: Clinical Rheumatology / Anthony Woolf . Volume 4.- 2010.[http://ees.elsevier.com/berh]
Methodical instruction has been worked out by: Prof. S.I. Smiyan
Methodical instruction was discussed and adopted at the Department sitting “
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
