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Methodological Instruction

June 22, 2024

METHODICAL INSTRUCTION FOR STUDENTS OF THE 6 COURSE

FOREIGN STUDENTS’ FACULTY

Module 3. Current practice in internal medicine

Content module 4. “Management of the patients with disorders of respiratory system”

LESSON № 1 (PRACTICAL – 6 HOURS)

Theme 14: Management of the patients with chronic cough. Management of the patients with syndrome of bronchial obstruction.

Aim: to learn and practice the skills of clinical diagnostics of the most informative sings of diseases with broncho-obstructive syndrome, to study laboratory and instrumental diagnostic, differential diagnostic and how to make the individual plan of treatment according to the reason, character and stage of broncho-obstructive syndrome and chronic cough.

Professional orientation of students. Based on pooled data from a number of studies, global prevalence of COPD was 7.5%, chronic bronchitis alone was 6.4%, and emphysema alone was 1.8%. The prevalence from 26 spirometric estimates was 8.9%. The most common spirometric definitions were those of the Global Initiative for Obstructive Lung Disease (GOLD). Thus, the prevalence of physiologically defined COPD in adults aged 40 years and older is approximately 9-10%. Absolute mortality rates for US patients aged 55-84 years (1985) were 200 per 100,000 males and 80 per 100,000 females. Internationally, a marked variation in overall mortality rates from COPD exists. The extremes are the more than 400 deaths per 100,000 males aged 65-74 years in Romania and the fewer than 100 deaths per 100,000 in Japan.

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 14.15-15.00

(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 of cough in the patients with disorders of respiratory system.

2. Pathogenesis of cough in the patients with disorders of respiratory system.

3. Peculiarities of treatment of cough in the patients with disorders of respiratory system.

4. Main clinical signs of syndromes.

– Bronchial spasm;

– inflamantory of airways;

– collection of sputum;

– obturation and compression of bronchi;

– tracheal stenosis and bronchial stenosis;

– hyper secretion of bronchial mucosa;

– Increase of sensory of bronchi.

5. Etiology of obstructive syndrome.

6. Pathogenesis and classification of obstructive syndrome.

7. Peculiarities of clinical sings of bronchial obstruction during different diseases (bronchitis, bronchial asthma, bronchoectasis disease, cancer of lungs and others)

8. Laboratory and instrumental methods of investigation of bronchial obstruction.

9. Peculiarities of treatment of patients with diseases with bronchial obstruction syndrome.

Test evaluation and situational tasks.

Choose the correct answer/statement:

1. One of the following condition is not associated with clubbing.

A. Primary biliary cirrhosis

B. Chronic bronchitis

C. Cryptogenic fibrosing alveolitis

D. Central bronchiectasis

E. Nothing of the above

2. A drug is to be delivered by a nebuliser. The size of a droplet for its humidification is :

A. <5

B. 5-10

C. 10-15

D. 15-20

E. All of the above

3. α1- Antitrypsin deficiency is associated with :

A. Centriaciner emphysema

B. Panaciner-emphysema

C. Irregular emphysema

D. Paraseptal-emphysema

E. All of the above

4. Volume of air taken into the lungs iormal respiration is known as :

A. Vital capacity

B. Timed vital capacity

C. Tidal volume

D. Inspiratory reserve volume

E. All of the above

5. For diagnosis of obstructive airway disease, which of the following measurement is usual

A. Vital capacity

B. Timed vital capacity

C. Tidal volume

D. Blood gas analysis

E. All of the above

6. All the following are true about Chronic Obstructive lung disease except:

A. Decreased FeV1

B. Decreased MEFR

C. Increased RV

D. Decreased diffusion capacity

E. Nothing of the above

7. FEV,/FVC is reduced in case of:

A. Pleural effusion

B. Lung fibrosis

C. COPD

D. All of the above

E. Nothing of the above

8. Decreased maximum mid-expiratory flow rate
indicates obstruction in:

A. Small airways

B. Trachea

C. Large airways

D. Trachea & Bronchi both

E. Nothing of the above

9. Features of restrictive lung disease is:

A. FEV₁/FVC decreases and compliance decreases

B. FEV₁/FVC increases and compliance increases

C. FEV₁/FVC decreases and compliance increases

D. FEV₁/FVC increases and compliance decreases

E. Nothing of the above

10. All are decreased in infiltrative lung disease, except:

A. Vital capacity

B. Alveolar arterial difference in PaO₂

C. Total lung capacity

D. Lung compliance

E. Nothing of the above

Real-life situations to be solved:

1. Man 60 y.o., complains on expiration dyspnea which increases at the physical exertion, cough with small amount of mucus-purulent sputum mostly in the morning. He is ill with COPD. Objectively: temperature – 36,0 °С, breathing rate – 22/min., pulse – 84/min., BP – 110/70. Skin is wet, diffuse cyanosis. Auscultation: breathing is hard, diffuse dry and moist wheezes are present. FEV – 62 %; pharmacological test with atrovent showed 5 % increasing of this index. What mechanism of bronchial obstruction development is the most possible in this case?

A. Hypercrynia

B. Inflammatory edema

C. Bronchial spasm

D. Diffuse sclerotic changes

E. Mucostasis

2. Patient of 52 has heavy attack of expiration dyspnea with severe moist cough with diffuse dry and moist wheezes, palpitation and diffuse cyanosis. What medicine is the most useful as the first aid?

A. Salbutamol

B. Strofantin

C. Lazolvan

D. Atrovent

E. Prednisol

3. An old woman complains of wheeze, dyspnoea and cough. She cannot sleep at night because of a chronic cough. Her CXR suggests hyperinflation. Spyrography: FEV1, FVC, Typhno index are low. What is the previous diagnosis?

A. Bronchogenic carcinoma

B. Emphysema

C. Respiratory failure

D. COPD

E. Bronchial asthma

4. A 24-yr-old car mechanic is brought to casualty by his girlfriend. She describes a 2-day history of rigors, sweats and intermittent confusion. On examination he is agitated, sweaty and pyrexial with 38.6° C. He is hyperventilating and cyanosed despite receiving O₂ by face mask. There is dullness to percussion and bronchial breathing at the left lung basse. What method of investigation is nesessary?

A. Spiral CT

with contrast

B. Chest X-ray

C. Arterial blood gases

D. Blood count and film

E. Urea and electrolytes

5. Woman 40 y.o., entered the clinic with complaints on severe dyspnea, which lasts for several hour. Astmopent, which was effective before, does not act. Palpitation and anxiety appeared. She is ill for 8 years ill with chronic bronchitis. Objectively: condition is severe, patient sits, keeps her hands at the edge of table, pale cyanosis, on the distance whistling breathing is heard. In lungs is present weak breathing with disseminated dry wheezes. Pulse – 108/min. BP -140/80. Prescription of what medicine as the first aid is obligatory in this case ?

A. Leukotrienes inhibitors

B. Adrenomimetics

C. Antihistamynic

D. Cholinolytics

E. Glucocorticoids

6. A middle-aged smoker presents with chronic cough and phlegm. His sputum is tenacious but not yellow or blood stained. His chest is hyperinflated. His arterial carbon dioxide is high and is arterial oxygen is low. What is the previous diagnosis?

A. Bronchitis

B. Bronchogenic carcinoma

C. Emphysema

D. Pneumonia

E. Respiratory failure

7. A 22-yr-old barman presents with a dry cough of sudden onset. He complains of a chest pain and rusty sputum. He also has a very high fever, rapid breathing, cyanosis and crepitations. Pneumonia was suspected. What is the most nesessary method of investigation?

A. Spirography

B. X-ray

C. Analysis of sputum

D. General blood analysis

E. ECG

8. During percussion of lungs in patient who got had barotrauma on a factory, was founded that lower borders of lungs are located one rib lower than normally, height and wideness of apexes of both lungs are considerably enlarged. What disease must doctor think about?

A. Exudative pleurisy

B. Emphysema of lungs

C. Chronic bronchitis

D. Bronchial asthma

E. Pneumothorax

9. Man of 43 complaints on dyspnea during physical exertion. Objectively: temperature 36,4 °С, breathing rate – 20/min., pulse – 78/min., BP-125/80. Emphysematous form of thorax. In lungs – vesicular breathing is weak. What research must be provided by patient at home for the decision of question about efficacy of prescribed broncholytics?

A. Spyrography

B. ECG-control of overload of right departments of heart

C. Peak-flowmetry

D. Bronchoscopy

E. Analysis of sputum (amount and microscopy)

10. A 53-yr-old smoker with chronic cough and copious yellow sputum presents in a state of agitation. He is confused. His pulse is bounding. He has a terrible headache and you find papilloedema on fundoscopy. What is the cause?

A. Bronchogenic carcinoma

B. Emphysema

C. Pneumonia

D. Respiratory failure

E. Bronchial asthma

11. Patient D., 60 years old. Carcinoma of right main bronchus was suspected. What is the nesessary method of investigation?

A. Fibreoptic bronchoscopy

B. Sputum culture

C. Mediastinoscopy

D. Spyrography

E. general blood analysis

12. A 35-yr-old accountant presents with a chronic cough, dyspnoea and wheezing. He produces copious sputum. His arterial carbon dioxide is low and his arterial oxygen is normal. X-ray: high pneumatization of lungs. What is your diagnosis?

A. Bronchogenic carcinoma

B. Emphysema

C. Pulmonary embolism

D. Pneumonia

E. Tuberculosis

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. Etiology of obstructive syndrome.

2. Pathogenesis and classification of obstructive syndrome.

3. Main clinical signs of syndromes.

– Bronchial spasm;

– inflamantory of airways;

– collection of sputum;

– obturation and compression of bronchi;

– tracheal stenosis and bronchial stenosis;

– hypersecretion of bronchial mucosa;

– Increase of sensory of bronchi.

4. Peculiarities of clinical sings of bronchial obstruction during different diseases (bronchitis, bronchial asthma, bronchoectatic disease, cancer of lungs and others)

5. Laboratory and instrumental methods of investigation of bronchial obstruction (interpretation of received results of sputum analysis, spyrography, spyrometry and peakflowmetry, roentgenography and tomography of chest organs).

6. Peculiarities of treatment of patients with diseases with bronchial obstruction syndrome.

7. Etiology of cough in the patients with disorders of respiratory system.

8. Pathogenesis of cough in the patients with disorders of respiratory system.

9. Peculiarities of treatment of cough in the patients with disorders of respiratory system.

Students should be able to:

1. To examine the patient with disorders of respiratory system (collection of complaints and anamnesis, objective examination of the patients).

2. To form a plan of laboratory and instrumental methods of investigation of the patients with disorders of respiratory system.

3. Estimate results of laboratory and instrumental methods of investigation.

4. To provide differential diagnostics of the lung diseases with syndrome of bronchial obstruction.

5. To form diagnoses of chronic obstructive pulmonary diseases and bronchial asthma.

6. Prescribe treatment for patients with COPD and bronchial asthma.

Correct answers of test evaluations and situational tasks:

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

Real-life situations. 1 – D, 2 – A, 3 – D, 4 – B, 5 – E, 6 – C, 7 – B, 8 – B, 9 – C,
10 – B, 11 – A, 12 – B.

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: Management of the patients with chronic cough.