METHODICAL INSTRUCTION FOR STUDENTS OF THE 6 COURSE

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 № 2 (PRACTICAL – 6 HOURS)

 

Theme 25: Management of patients with hemorrhagic diathesis

 

Aim: to develop skills and to acquire experience relevant to management of patients with different types of hemorrhagic diathesis.

 Professional orientation of students It is necessary to know the clinical symptoms, laboratory investigation and treatment of this pathology, because it is a very widespread disease. Bleeding diathesis is an unusual susceptibility to bleeding (hemorrhage) due to a defect in the system of coagulation. Several types are distinguished, ranging from mild to lethal.

 

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.                Definition of the hemorrhagic syndrome“ and “hemorrhagic diathesis.”

2.                Current classification of hemorrhagic diathesis.

3.                Etiology, pathogenesis of hemorrhagic diathesis in the patients with disorders of coagulation, platelet and vessel wall.

4.                Clinical manifestation of the different hemorrhagic diathesis.

5.                Clinical manifestation of the hemophilia type A and B, thrombocytopenia, hemorrhagic vasculitis.

6.                Laboratory tests for hemorrhagic diathesis.

7.                Management of the hemorrhagic diathesis, emergency in hemorrhagic diathesis.

8.                Medications of the primary and secondary prophylaxis.

9.                Clinical manifestation of the thrombocytopenia (TTP, ITP, HUS)

10.           Principles of the thrombocytopenia therapy.

11.           Clinical manifestation of the hemophilia.

12.           Emergency care at hemophilia bleeding.

13.           Medications of the primary and secondary prophylaxis.

 

Test evaluation and situational tasks.

1. Christmas disease is treated by

A. F.F. blood

B. F.F. plasma

C. Cryoprecipitate

D. Steroids

E. Vincristine

2. Most important aspect of treatment of DIC :

A. Heparin

B. FFP and cryoprecipitate

C. Treat the primary cause

D. Fluids

E.F.F. plasma

3. Fragmented RBC’s are seen in

A. ITP

B. Spherocytosis

C. DIC

D. Patient on cardiac valves

E. CLL

4. Oral anticoagulant therapy is monitored with indexes

A. INR

B. PTT

C. TT

D. Clot lysis time

E. Bleeding time

5. Patients with coagulation abnormality due to liver diseases are likely to have :

A. Prolonged bleeding time

B. Thrombocytosis

C. Prolonged prothrombin time

D. Decreased partial thromboplastin time

E. Bleeding time prolonged

6.  Patient on heparin therapy should be monitored with:

A. Clotting time

B.  Bleeding time

C.  Prothrombin time

D. Fibrinogen

E.  Bleeding time

7.  Heparin’s mode of action is

A. Not easily controlled

B. Inhibits factor VII synthesis

C. Inhibits synthesis of thrombin

D. Activates plasmin

E. Blocks fibrinogen

8.  In von Willebrand’s disease, which is true :

A. Normal prothrombin time

B. Decreased platelet

C. Normal partial thromboplastin time

D. Decreased platelets

E.  None of above

9. Haemophilia A is characterised by the presence of following features, except

A. Bleeding into soft tissues, muscles & joints

B. Loss factor VIII levels

C. Prolonged prothrombin time

D. Prolonged partial thromboplastin time

E.  All is true

10. Factor deficiency in Christmas disease is

A. IX

B. II

C. VII

D. VIII

E.  XI

 

Real-life situations to be solved:

1. A 67-year-old man who had peripheral vascular surgery 2 months ago is hospitalized because of substernal chest pain and electrocardiographic changes consistent with myocardial ischemia. His hemoglobin is 12.2 g/dL, leukocyte count is 7300/μL, and platelet count is 235,000/μL. An infusion of unfractionated heparin is initiated, but pain persists intermittently. Two days after admission, his repeat platelet count is 90,000/μL. What is the most appropriate management for this patient?

2. A 67-year-old woman has an uncomplicated myocardial infarction. She returns to the hospital 2 weeks later for cardiac catheterization, which shows three-vessel coronary artery disease. Coronary artery bypass grafting is recommended, and the patient undergoes an uncomplicated procedure 2 weeks later. Her platelet count immediately before her surgery is 325,000/μL, and the day after is 210,000/μL. She is discharged 3 days after surgery with the platelet count not having been repeated. Four days later she is evaluated in the emergency department because of shortness of breath. She is afebrile, and radiography of the chest shows no infiltrates. Platelet count at this time is 85,000/μL, prothrombin time and activated partial thromboplastin time are both normal, and peripheral blood smear shows only decreased numbers of platelets. A ventilation-perfusion lung scan is indeterminate, and low-molecular-weight heparin therapy is empirically initiated to treat a presumed pulmonary embolism. The following morning, the patient’s platelet count is 25,000/μL, and the patient has developed acute ischemia of her right foot. What is the most likely cause of her thrombocytopenia?

 

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.                Schema of hematopoiesis.

2.                Main mechanisms of hemostasis.

3.                Cells, tissue and plasma factors of hemostasis.

4.                Phases of blood coagulation.

5.                Kinds of hemorrhagic diathesis.

6.                Laboratory tests of hemostatic system.

7.                Criteria for diagnosis of hemorrhagic diathesis.

8.                Definition of the hemorrhagic syndrome“ and “hemorrhagic diathesis.”

9.                Current classification of hemorrhagic diathesis.

10.           Etiology, pathogenesis of hemorrhagic diathesis in the patients with disorders of coagulation, platelet and vessel wall.

11.           Clinical manifestation of the different hemorrhagic diathesis.

12.           Clinical manifestation of the hemophilia type A and B, thrombocytopenia, hemorrhagic vasculitis.

13.           Laboratory tests for hemorrhagic diathesis.

14.           Management of the hemorrhagic diathesis, emergency in hemorrhagic diathesis.

15.           Medications of the primary and secondary prophylaxis.

 

Students should be able to:

1. Put diagnosis of chronic idiopathic thrombocytopenic purpura, trombotic thrombocytopenic purpura, heparin–induced thrombocytopenia, hemophilia.

2. Prescribe treatment for patients with idiopathic thrombocytopenic purpura, trombotic thrombocytopenic purpura, Heparin–induced thrombocytopenia, hemophilia

 3. Give emergency therapy for patient with hemorrhagic syndrome.

 

Correct answers of test evaluations and situational tasks:

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

Real-life situations. 1. . Discontinue the heparin infusion and institute thrombin-inhibitor therapy. 2.Heparin-induced thrombocytopenia

 

References.

A – 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 PATIENT WITH HEMORRHAGIC DIATHESIS

 

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)    b) http://emedicine.medscape.com/leukemia

b)    c) http://meded.ucsd.edu/clinicalmed/introduction.htm

c)     d) http://www.gfmer.ch/Guidelines/Anemia_and_hemoglobinopathies/Anemia.htm

 

Methodical instruction has been worked out by assoc. prof. U.S.Slaba

Methodical instruction was discussed and adopted at the Department sitting  “29” June, 2010, protocol № 19

Methodical instruction was adopted and reviewed at the Department sitting “16” June, 2011, protocol № 13

Methodical instruction was adopted and reviewed at the Department sitting “12” June, 2012, protocol № 12

Methodical instruction was adopted and reviewed at the Department sitting “25” June, 2013, protocol № 17