METHODICAL INSTRUCTION FOR STUDENTS OF THE 4 COURSE

foreign students’ Faculty

MODULE 2. PRINCIPLES OF INTERNAL MEDICINE

(cardiology, rheumatology, nephrology, common questions of internal medicine)

Content module 3. “Principles of diagnosis, management and prevention of main kidney and urinary tract diseases”

LESSON № 5 (PRACTICAL – 6 HOURS)

 

Theme 22. Tubulointerstitial nephritis. Amyloidosis of kidneys

 

Aim: to study the pathogenesis, clinic, diagnostic criteria of tubulointerstitial nephritis and renal amyloidosis; to be able to examine patients with kidney disease, assess renal function, identify specific clinical and laboratory-instrumental symptoms of tub tubulointerstitial nephritis and renal amyloidosis, to group them into syndromes, to devote leading syndrome; to conduct differential diagnosis, to formulate clinical diagnosis, to prescribe differentiated treatment program for patients with nephritis tubulointerstitial and renal amyloidosis, to determine the degree of loss of working capacity, to determine indications for sanatorium and resort treatment.

 

Professional orientation of students: Primary tubulointerstitial diseases (ie, diseases of the renal tubules and interstitium sparing the glomeruli) constitute 10-15% of all kidney diseases both in theUnited States and around the world. In certain regions, such as the Balkans (ie, Bosnia, Croatia, Romania, Bulgaria), where endemic nephropathy is common, interstitial diseases may be more prevalent. Primary systemic amyloidosis occurs in around 8 per million people per year, which is approximately 3,000 new patients annually in the US. In the UK, the age-adjusted incidence is between 5.1 and 12.8 per million per year, with around 60 new cases annually. Median age at diagnosis is 64 years, but patients can present at any age. The male-to-female ratio is nearly 2:1. There are no ethnicity studies for amyloidosis, but the incidence of multiple myeloma and monoclonal gammopathy of unknown significance is twice as common in black people and it has been surmised that this would be true of amyloidosis as well. The incidence of all monoclonal gammopathy associated disorders is lower in Asian populations. The incidence of secondary amyloidosis in the US has been falling over the decades, and accounts for only 3% of systemic amyloidosis. In Europe, AA amyloidosis can account for 10% of systemic amyloidosis. Although the exact incidence of CRF (chronic renal failure) at its different stages is unknown, ESRD (End Stage Renal Disease) has reached epidemic levels, causing a major burden to health care resources. The incidence of new patients with ESRD in the United States in 1998 was 85,520, representing an incidence rate of 308 cases per million population; the prevalence on December 31, 1998, was 323,821 patients, representing a prevalence rate of 1160 cases per million population. An annual increase in incidence rate of approximately 7% per year since 1978 has occurred. The 5-year survival rate for a patient undergoing chronic dialysis in the United States is approximately 35%. This is approximately 20% in patients with diabetes.

 

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) (for clinical department):

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 Tubulointerstitial nephritis. Etiology, pathogenesis

2.                Clinical manifestations of Tubulointerstitial nephritis.

3.                Laboratory and instrumental investigations of patients with Tubulointerstitial nephritis

4.                Diagnostic criterion and differential diagnosis of Tubulointerstitial nephritis.

5.                Complications.

6.                Principles of treatment of Tubulointerstitial nephritis. Emergency care in case of ARF.

7.                Prophylaxis, Prognosis, professional capacity of patients with tubulointerstitial nephritis

8.                Definition of renal amyloidosis. Etiology, pathogenesis, classification.

9.                Clinical manifestations of amyloidosis.

10.            Laboratory and instrumental investigations of patients with renal amyloidosis.

11.           Diagnostic criteria and differential diagnosis of renal amyloidosis.

12.           Complications.

13.           Principles of treatment of renal amyloidosis.

14.           Prophylaxis. Prognosis, professional capacity of patient with renal amyloidosis.

 

Test evaluation and situational tasks.

Choose the correct answer/statement:

1.                What disease leads to renal amyloidosis?

A.              Chronic glomerulonephritis

B.               Collagen nephropathy

C.               Renal tuberculosis

D.              Acute interstitial nephritis

E.               Diabetic nephropathy

2.                The most common manifestation of rheumatoid nephropathy is:

A.              Membranous glomerulonephritis.

B.               Amyloidosis.

C.               Chronic interstitial nephritis.

D.              Chronic pyelonephritis.

E.               Nephroangiosclerosis.

 

3.                In what diseases nephrotic syndrome is absent?

A.              Diabetic glomerulosclerosis

B.               Renal amyloidosis

C.               Acute glomerulonephritis

D.              Tubulointerstitial nephritis

E.               Chronic glomerulonephritis

 

4.                What symptom is characterized for tubulointerstitial nephritis?

A.              Bacteriuria

B.               Hipoizostenuriya

C.               Hypertension

D.              Dysuria

E.               Nocturia

5.                What are the common findings of IgA nephropathy?

A.              Heavy proteinuria

B.               White cells;

C.               Isolated proteinuria

D.              Pyuria

E.               Gross hematuria post exercise or viral illness

6.                . What are six common etiologies of membranous nephropathies?

A.               Idiopathic, syphilis, Hepatitis B, SLE, gold salts, and malignancy

B.                Idiopathic, chronic heart failure, Hepatitis B, SLE, gold salts, and malignancy

C.                Idiopathic, syphilis, Hepatitis A, SLE, gold salts, and malignancy

D.               Idiopathic, syphilis, Hepatitis B, SLE, NSAIDs, and malignancy

E.                Idiopathic, syphilis, Hepatitis B, SLE, gold salts, and bronchial asthma

 

Real-life situations to be solved:

1. Patient P., 56 y, suffering from rheumatoid arthritis over 15 years. After nephrotic syndrome identifying patient was held survey in which amyloid was found. What is the most likely diagnosis? What medications required to treat of kidney damage?

2. Patient, 50 years old, has a fibro-cavernous pulmonary tuberculosis. Recently, he noticed the appearance of swelling in the lower extremities. Proteinuria, cylindruria marked in urine. What is the most likely cause of changes in the urine sample? What medications required to treat of kidney damage?

 

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.                Anatomy and physiology of the kidneys.

2.                Normal quantities of the main clinics and biochemical homeostasis.

3.                Pathogenensis of the main clinical manifestations of the renal diseases.

4.                General and specific syndromes occur in patients with tubulointerstitial nephritis, amyloidosis.

5.                The main laboratory and instrumental investigations in patients suffering from tubulointerstitial nephritis, amyloidosis.

6.                Principle of treatment of tubulointerstitial nephritis, amyloidosis.

7.                Prophylaxis. Prognosis, professional capacity of patients with tubulointerstitial nephritis, amyloidosis.

 

Students should be able to:

1.                To collect complaints, anamnesis data

2.                To make physical examination the patients with renal diseases.

3.                To interpret clinical, laboratory and instrumental investigation in patients with tubulointerstitial nephritis, amyloidosis.

4.                To find clinical and laboratory-instrumental syndromes.

5.                To make differential diagnosis between tubulointerstitial nephritis and acute pyelonephritis, between tubulointerstitial nephritis and acute glomerulonephritis.

6.                To formulate clinical diagnosis of tubulointerstitial nephritis, amyloidosis.

7.                To prescribe treatment of patients with tubulointerstitial nephritis, amyloidosis.

 

Correct answers to the tests and case studies:

Tests: 1. C; 2. В; 3; D. 4. B; 5. E; 6. A.

Real-life situations to be solved: 1. Amyloidosis, Glucocorticosteroids. 2. Renal amyloidosis. Patient needs treatment of tuberculosis and also treatment of renal amyloidosis.

 

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:

a) www.tdmu.edu.ua: Tubulointersticial nephritis and amyloidosis of kidneys

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

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

 

B – Additional:

1. Lawrence M. Tierney, Jr. et al: Current Medical Diagnosis and treatment 2000, Lange Medical Books, McGraw-Hill, Health Professions Division, 2000.

 

 

Methodical instruction has been worked out by:  assist. prof. Kvasnitska O.S.

Methodical instruction was discussed and adopted at the Department sitting “27” August, 2013. Minute № 1