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METHODICAL INSTRUCTION FOR STUDENTS OF THE 6 COURSE

June 13, 2024

METHODICAL INSTRUCTION FOR STUDENTS OF THE 6 COURSE

foreign students’ Faculty

Module 3: Current practice of internal medicine

Content module 3: Management of patients with disorders of gastrointestinal tract, liver and pancreatic diseases

LESSON № 1 (PRACTICAL – 6 HOURS)

Theme 11.Management of patient with dyspepsia

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

Professional orientation of students. complaints among the population. In the developed countries the frequency of dyspepsia syndrome in the population ranges from 25-28% (Denmark, Sweden, USA, Norway) to 34-41% (Australia, UK). Dyspeptic complaints are the cause of 4-5% of all calls to general practitioners.
GERD – one of the most common potentially dangerous gastrointestinal disease, which, WHO experts suppose, will be the disease of XXI century. Symptoms of GERD are seen in almost 40% of the adult population, therefore, such disorder significantly reduces the quality of life of patients. There are numbers of complications of GERD, including Barrett’s esophagus and adenocarcinoma of the esophagus.
HG – fairly common pathology, which affects 20-30% of total adult population of the planet, it continues to hold a leading position in the structure of gastroenterological diseases. HG, as a multifactorial polietiological disease, causes metabolic, morphological and functional disorganization of the stomach.
PUs of stomach and duodenum are the most common disorders of the digestive canal: they are diagnosed in almost 10% of the population of Europe and 15% of the population of America. Frequency of surgical interventions for uncomplicated ulcers decreases due to the wide clinical use of pathogenic conservative therapy. The frequency of complications of PU, leading to prolonged and permanent disabilities and sometimes death, ranges from 6,5 to 22,3%. Knowledge of modern methods of medical diagnostics of this pathology and the ability to prescribe an adequate therapy in time may save the lives of such patients or significantly reduce the incidence of complications.

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, etiology and pathogenesis of the GERD

2. Basic clinical and laboratory diagnostic criteria of the GERD

3. Treatment of the GERD

4. Stomack dyspepsia: diagnostic criteria, treatment.

5. Etiology and pathogenesis of ulcer disease

6. The diagnostic criteria of ulcer disease

7. Treatment of patients with ulcer disease

8. Etiology and pathogenesis of chronic gastritis

6. The diagnostic criteria of chronic gastritis

7. Treatment of patients with chronic gastritis

Test evaluation and situational tasks.

Choose the correct answer/statement:

1. An esophagogastroduodenoscopy is generally not indicated for evaluating:

A. Asymptomatic or uncomplicated sliding hiatal hernia

B. Pain in the upper abdomen

C. Nausea

D. Vomiting

E. Gastroesophageal reflux disease (GERD)

2. An esophagogastroduodenoscopy is generally not indicated for evaluating:

A. Asymptomatic or uncomplicated sliding hiatal hernia

B. Nausea

C. Vomiting

D. Gastroesophageal reflux disease (GERD)

E. Difficulty swallowing (dysphagia)

3. The most-common symptom of GERD is

A. Heartburn

B. Pain with swallowing (odynophagia)

C. Regurgitation

D. Nausea

E. Chest pain

4. Extraesophageal manifestations of GERD are all of the following except

A. Diverticulutis

B. Laryngitis (hoarseness, throat clearing)

C. Asthma

D. Erosion of dental enamel

E. Sinusitis

5. An esophagogastroduodenoscopy is indicated in all following conditions except:

A. Asymptomatic or uncomplicated sliding hiatal hernia

B. Pain in the upper abdomen

C. Vomiting

D. Gastroesophageal reflux disease (GERD)

E. Difficulty swallowing (dysphagia)

6. The most common cause of esophagitis is

A. Gastroesophageal reflux disease

B. Viral esophagitis

C. Herpes simplex (Herpetiform esophagitis)

D. Ingestion of acid solution

E. Radiation therapy

7. Drug-induced gastritis may be caused by all of the following except

A. Euphyllini

B. Diclofenac

C. Ibuprofen

D. Indomethacin

E. Piroxicam

8. A 42-year-old cigarette smoker complains of well localized burning epigastric pain, nonradiating. The most sensitive way to make a specific diagnosis is

A. Barium x-ray

B. Endoscopy

C. Serologic test for Helicobacter pylori

D. Serum gastrin

E. Ultrasound

9. Indications for Diagnostic Esophagogastroduodenoscopy are all of the following conditions except

A. Possible perforation

B. Unexplained anemia (usually along with a colonoscopy)

C. Upper gastrointestinal bleeding as evidenced by hematemesis or melena

D. Dysphagia – difficulty in swallowing

E. Odynophagia – painful swallowing

10. Peptic ulcer should be differentiated with all of the following except

A. Stomach cancer

B. Gastritis

C. Referred pain (pleurisy, pericarditis)

D. Pancreatitis

E. Bronchial asthma

Real-life situations to be solved:

1.Patient J., 35 y.o., complains on a feeling of heaviness in the epigastric region, nausea, unpleasant taste in the mouth, an unstable stool, loose of weight. He is sick for 7 years. Objectively: pale skin. At palpation – a slight diffuse tenderness in the epigastric region. Moderate hypochromic anemia. The absence of free НСІ in gastric juice in response to action of histamine. Radiological findings: thickening of the folds of the gastric mucosa, shortening and narrowing of the antrum, peristalsis in this zone is absent. A biopsy of antral part shows the signs of atrophy, areas of gastric metaplasia. Diagnosis?
2. The patient Y., 34 years old, complains on a slight pain in the epigastric region, bloating, regurgitation after repeated food poisoning. He is sick for 4 years. Objectively: slight pallor of the skin and mucous membranes, diffuse tenderness in the epigastrium. Radiological findings: gastroptosis, smoothing of the folds of mucous, weak peristalsis, the evacuation is suppressed, pylorus is hypotonic. Your preliminary 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. General anatomy and physiology of digestive system

2. Relevant terminology, definitions and classifications of dyspepsia

3. Chief complaints of patients with dyspepsia

4. Evaluation of basic signs and symptoms in patients with dyspepsia

5. Specific signs and symptoms of patients with dyspepsia

6. Methods of physical examination of patients with dyspepsia

7. Methods of laboratory evaluation of patients with dyspepsia

8. Methods of instrumental evaluation of patients with dyspepsia

9. Principles of management of patients with dyspepsia

Students should be able to:

1. Perform a clinical exam of patients with dyspepsia

2. Reveal main clinical syndromes.

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

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

Real-life situations. 1. Atrophic gastritis. 2. Chronic gastritis

References

A – Basic:
1. Davidson’s Principles and Practice of Medicine / Edited by Nicki R. Colledge, Brian R. Walker , Stuart H. Ralston, 1st Edition. – – Philadelphia : Churchill Livingstone, 2010. – 1376 p.

2. Harrison’s Principles of Internal Medicine. Dan L.Longo M.D. – New York : McGraw-Hill, 2012. – 4012 p.

3. Harrisons Principles of Internal Medicine Self-Assessment and Board Review /

Charles M. WienerAnthony S. Fauci, Eugene Braunwald, Dennis L. Kasper, Stephen L. Hauser, Dan L. Longo, J.Larry Jameson, Joseph Loscalzo, Cynthia Brown, 18th Revised edition. – New York : McGraw-Hill Education – Europe, 2012. – 512 p.

4. The Merck Manual of Diagnosis and Therapy / Edited by Robert S. Porter., 19th Revised edition. – London : Elsevier Health Sciences, 2011. – 3754 p.

5. Web–sites: www.tdmu.edu.ua: Management of patients with dyspepsia

B – Additional:

1.Textbook of Clinical Gastroenterology and Hepatology (2nd Revised edition) /

Edited by C. J. Hawkey, Jaime Bosch, Joel E. Richter, Guadalupe Garcia-Tsao, Francis K. L. Chan. – Chicester : John Wiley and Sons Ltd, 2012. – 1272 p.

2. Oxford Handbook of Gastroenterology and Hepatology (2nd Revised edition). Stuart Bloom, George Webster, Daniel Marks. – Oxford : Oxford University Press, 2012. – 648 p.

3. Harrison’s Gastroenterology and Hepatology (1th edition). Dan L. Longo, Anthony S. Fauci. – New York : McGraw-Hill Education – Europe, 2010. – 752 p.

4. Mayo Clinic Gastroenterology and Hepatology Board Review (4th Revised edition). Stephen Hauser. – Oxford : Oxford University Press Inc., 2011. – 480 p.