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 № 4 (PRACTICAL – 6 HOURS)
Theme 10. Management of patients with systemic vasculitis (hgemoragicvasculitis (GV), hypersensitivity vasculitis (HV) and Polyarteritis nodosa (PAN).
Aim:to perfect ability to inspect patients with systemic vasculitis pathology for studentsto teach students to find out the separate clinicaland laboratory instrumental symptoms of gemoragicvasculitis (GV), hypersensitivity vasculitis (HV) and Polyarteritis nodosa (PAN), to group them insyndromes, to select a leading syndrome; to conduct the differential diagnosis of GV and HP;to formulate a clinicaldiagnosis; to appoint the differentiated programs of treatment a patient on GV,GSV and HP in obedience to clinical protocols of grant to medicare,ratified MOZ; to determine a prognosis.
Professional orientationofstudents. GV is vasculitis with immune deposits, at which shallow vessels (capillaries), the typical signs of which are changes from the side of skin, intestineand buds, in combination with arthralgia or arthritis. It should be noted that GV one of most widespread systemic vasculitis, that usually meets forchildren and teenagers. Prevalence arrives at him 13,5 on 100 thousands of persons under age 16. At HV shallow vessels are also struck. It is theisolated skin leucocytoclastic vasculitis without systemic vasculitis or glomerulonephritis, that without bringing in of vessels of other organs. PAN isnecrosing vasculitis of middle and shallow arteries, at which to the pathological process a skin, joints, peripheral nerves, intestine and buds, is broughtover. Prevalence of VP is 0,46 – 7,7 on 100 thousands of population, morbidity – 0,2 –1 on 100 thousands of population. Characterized by the highindexes of death rate and lethality, thus during first-year of disease.
MethodologyofPracticalClass
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.
· Describetheresultsoftheabovetestsintermsoftherelatedpathophysiology.
· 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.
· Monitorresponsetotherapy.
Seminardiscussion oftheoreticalissues
1. Definitionof HV, PAN, GV.
2. Criteria for diagnosis HV, PAN, GV
3. Examinationofthepatientwith HV, PAN, GV .
4. SyndromesforSystemicsclerosisanddifferentialdiagnosisof HV, PAN, GV.
5. Evaluateresultsofinvestigationsofdiagnosisof HV, PAN, GV.
6. Makingdiagnosisof HV, PAN, GV.
7. Makeplanofinvestigationsofpatientswith HV, PAN, GV.
8. Differentialdiagnosisof HV, PAN, GV.
9. Treatmentof HV, PAN, GV.
10. The role of DMARDs and symptomatic treatment in HV, PAN, GV.
Test evaluation and situational tasks.
MultipleChoiceQuestions
Choosethecorrectanswer/statement
1. Toxic Side Effects of cyclophosphamide areallofthefollowing EXCEPT
A. Bone marrow suppression
B. gastropathy
C. Cystitis
D. Bladder carcinoma
E. Gonadal suppression
2. Henoch-Schönleinpurpura (HSP) is a small-vessel vasculitis characterized by all of the following EXCEPT
A. skin purpura
B. arthritis
C. abdominal pain
D. hematuria
E.epistaxis
3. A 47 year old woman had a 25 year history of recurrent painful nodules on the medial aspect of her ankles. Episodes lasted for 4-6 months with complete resolution of the rash during symptom free periods for several months. He has had fever, weight loss, arthralgias, his BP 160/110 mm Hg, temperature is
A. Lymphoma, with a paraneoplastic syndrome
B. Takayasus arteritis
C. Systemic lupus erythematosus
D. Polyarteritisnodosa
4. A 25-year-old man had a 7 month history of progressive, painful, pruritic ulcers on both legs. He had no evidence of systemic disease. A skin biopsy revealed a vasculitis involving medium size arteries. The hyperpigmented patches represent the new phase of the lesions – tender dermal nodules. Choosethesinglemostlikelytreatmentfromthelistofoptionsgivenbelow.
A. Prednisone
B. Tetracycline
C. Ciprofloxacin
D. Beta 2 agonist
E. IV aminophylline
5. Which of the following test isn’t included in laboratory studies of vasculitis?
A. complete bloodcount
B. erythrocyte sedimentation rate
C. level ofserumCa
D. urinalysis
E. hepatitis B surfaceantigen
6. A 19-year-old student has a several-days history of aching pains in knees, ankles, and intermittent abdominal pain. Three days ago, he had two episodes of painless hematuria. He has had an intermittent, nonpruritic rash located below the knees bilaterally. He has no history of kidney disease or intravenous drug use. On examination, the patient appears well, temperature is
A. Prednisone 20 mg/d
B. Prednisone 15 mg/d
C. Ciprofloxacin, NSAIDs
D. Prednisone 30 mg/d
E. Tetracycline, prednisone
7. Hypersensitivity vasculitis effects mainly …
A. vessels of skin
B. vessels of kidney
C. vessels of lung
D. coronary arteries
E. vessels of brain
8. Signs of kidney involvement in Polyarteritisnodosa are all of the following EXCEPT:
A. Systemic hypertension
B. Painless hematuria
C. hydronephrosis
D. Intrarenal aneurysms
9. A 29-year-old woman is evaluated because of a year history of skin ulcers on her lower extremities, and myalgias. The ulcers usually begin with tender, erythematous nodules that then ulcerate and are resistant to treatment. A previous punch biopsy of the skin allegedly showed thrombotic lesions in small blood vessels of the dermis, polymorphonuclear neutrophils infiltrate all layers of the vessel wall and perivascular areas. The physical examination is remarkable for the ulcers, and also for a diffuse livedoreticularis pattern of skin discoloration and wasting of the web space between the thumb and index finger on the left hand. Her ability to grasp with that hand is minimal. She has a right foot drop. Which of the following diagnoses is the most likely cause of this patient’s symptoms?
A. Lymphoma, with a paraneoplastic syndrome
B. Takayasus arteritis
C. Systemic lupus erythematosus
D. Polyarteritisnodosa
10. A 24-year-old graduate student has a several-week history of aching pains in knees, ankles, and elbows and intermittent abdominal pain. Three days ago, he had two episodes of painless hematuria. He has had an intermittent, nonpruritic rash located below the knees bilaterally. He takes acetaminophen occasionally for the aching joints. He has no history of kidney disease or intravenous drug use. On examination, the patient appears well, temperature is
Urinalysis Specific gravity 1.030, pH 5.0, 1 + proteinuria, 4+ hematuria
Biopsy of skin lesion shows IgA depositio. What is the most likely cause of renal disease in this patient?
A. Lupus nephritis
B. Acute poststreptrococcal glomerulonephritis
C. Henoch–Schenleinpurpura
D. Allergic interstitial nephritis
Real-life situations to be solved:
2 real-lifesituationtobesolved
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. Relevantterminology, definitionsandclassificationsof PAN, GV, HV.
2. Chiefcomplaintsofpatientswith PAN, GV, HV.
3. Evaluationofbasicsignsandsymptomsof PAN, GV, HV.
4. Specificsignsandsymptomsof PAN, GV, HV.
5. Methodsofphysicalexaminationofpatientswith PAN, GV, HV.
6. Methodsoflaboratoryevaluationofpatientswith PAN, GV, HV.
7. Methodsofinstrumentalevaluationofpatientswith PAN, GV, HV.
8. Principlesofmanagement.
Students should be able to:
1. Definitionof HV, PAN, GV.
2. Criteria for diagnosis for HV, PAN, GV.
3. Examination of patientswith HV, PAN, GV.
4. Syndromesanddifferentialdiagnosisfor HV, PAN, GV
5. Evaluateresultsofinvestigationsof HV, PAN, GV.
6. Makingdiagnosisof HV, PAN, GV.
7. Makeplanofinvestigationsofpatientswith HV, PAN, GV.
8. Differentialdiagnosisof HV, PAN, GV.
9. Treatmentof HV, PAN, GV.
10. The role of DMARDs and symptomatic treatment in HV, PAN, GV.
Correct answers of test evaluations and situational tasks:
Multiple Choice Questions. 1 – B. 2 – A. 3 – E. 4-B. 5-B. 6-D. 7-E. 8-A. 9-E. 10-A.
Real-life situations.
The correct answers
References.
А-Basic:
1. Davidson’sPrinciplesandpracticeofmedicine (21st revised ed.) / byColledge N.R., Walker B.R., andRalston S.H., eds. – ChurchillLivingstone, 2010. – 1376 p.
2.
3. TheMerckManualofDiagnosisandTherapy (nineteenthEdition)/ RobertBerkow, Andrew J. Fletcherandothers. – publishedbyMerckResearchLaboratories, 2011.
4. Web –sites:
a) http://intranet.tdmu.edu.ua : Management of patients with systemic vasculitis
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. VasculitisinClinicalPractice,1st Edition/ Richard A. Watts; ); David G. I. Scott/ Springer.- 2010.- p. 215.
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
