METHODICAL INSTRUCTION FOR STUDENTS OF THE 6 COURSE
foreign students’ Faculty
module 3. current practice in internal medicine
Content module 6. “Management of patients with renal disorders”
LESSON № 2 (PRACTICAL – 6 HOURS)
Theme 22: Management of patients with nephrotic syndrome. Management of patients with renal arterial hypertension.
Aim: to learn criteria for diagnosis, differential diagnosis, treatment, prognosis of the diseases with nephroticsyndrome and renal arterial hypertension.
Professional orientation of students: Acute nephritic syndrome is the most serious and potentially devastating form of various renal syndromes. Acute glomerulonephritis is characterized by the abrupt onset of hematuria and proteinuria, often accompanied by azotemia (ie, decreased glomerular filtration rate [GFR]) and renal salt and water retention. Nearly all forms of acute glomerulonephritis typically progress to chronic glomerulonephritis. The condition is characterized by irreversible and progressive glomerular and tubulointerstitial fibrosis, ultimately leading to a reduction in the GFR and retention of uremic toxins. If disease progression is not halted with therapy, the net result is chronic kidney disease (CKD), end-stage renal disease (ESRD), cardiovascular disease, and death. The diagnosis of CKD can be made without knowledge of the specific cause.
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. Modern views of the etiology, pathogenesis, classification of glomerulonephritis, diabetic nephropaty, renal amiloidosis
2. Modern approaches to the mechanisms of development of leading clinical, laboratory sings of the nephrotic syndrome
3. Management of the nephrotic syndrome.
4. Treatment of the immune-inflammatory renal diseases (glomerulonephritis) mith nephrotic symndrome.
4.1. Dietotherapy.
4.2. Diuretics.
4.3. Glucocorticoids.
4.4. Immunosuppressive therapy.
4.5. Heparinotherapy.
4.6. Platelet aggregation inhibitor.
4.7. Angiotensin-converting enzyme (ACE) inhibitors.
4.8. Physiotherapy and phytotherapy.
4.9. Treatment of the local hemodynamic disorders.
5. Corection of the secondary immunologic insufficient.
6. Prophylactic medical examination and sanatorium-resort therapy in the renal disorders.
7. Treatment of the non immune renal diseases (diabetic nephropaty, renal amiloidosis) mith nephtotic symndrome.
8. Modern views of the etiology, pathogenesis, classification of renal arterial hypertension
9. Management of of renal arterial hypertension
10. Treatment of renal arterial hypertension.
Test evaluation and situational tasks.
Choose the correct answer/statement:
1. Acute course of glomerulonenhritis may occur on morphological case of
A. IgA nephropathy
B. minimal change disease
C. Proliferative glomerulonephritis
D. Membranous nephropathy
E. Mesangioproliferative glomerulonephritis
2. The Diet of patient with nephrotic syndrome has to exclude
A. Increased content of Salt
B. Increased content of fats
C. Increased content of proteins
D. All of then
E. None of them
3. What percent of adult idiopathic nephrotic syndrome is caused by minimal change disease?
A. 20%
B. 30%
C. 40%
D. 50%
E. 10%
4. What is the most common form of idiopathic glomerulonephritis?
A. IgA nephropathy
B. minimal change disease
C. Proliferative glomerulonephritis
D. Membranous nephropathe
E. Mesangioproliferative glomerulonephritis
5. What are the common findings at presentation of acute glomerulonephritis?
A. Oliguria
B. Hypertension
C. Active urine sediment
D. Proteinuria which is rarely nephrotic range
E. All of them
6. What amount of proteinuria per day is indicative of nephrotic syndrome?
A. Proteinuria of more than 3.5 grams/day
B. Proteinuria of more than 2.5 grams/day
C. Proteinuria of more than 1.5 grams/day
D. Proteinuria of more than 3.0 grams/day
E. Proteinuria of more than 2.0 grams/day
7. Describe important findings in post streptococcal glomerulonephritis following pharyngitis?
A. -20 day latent period
B. ASO >250 u/ml
C. Low C3
D. Following cutaneous strep infections there is a 14-21 day latent period and normal ASO titers
E. All of them
8. The nephrotic syndrome is characterized by all of following except:
A. heavy proteinuria;
B. hypoproteinaemia;
C. light proteinuria;
D. hyperproteinaemia;
E. generalized oedema.
9. Which is the most appropriate antihypertensive therapy for patient with glomerulonephritis?
A. Intensive lifestyle modification
B. Diuretic
C. Nondihydropyridine calcium channel blocker
D. Angiotensin-converting enzyme inhibitor
E. Beta-blockers
10. Glomerular filtration rate should be estimated by using:
A. Measurement of serum creatinine
B. Calculation of the timed 24-hour creatinine clearance
C. Measurement of the clearance of 125I-iothalamate or inulin
D. Cockcroft-Gault or Modification of Diet in Renal Disease formula
E. None of them
Real-life situations to be solved:
2. Select the drug which is given in usual dosages, may be effective in treating urinary tract infections in patients with acute renal failure.
a) Gentamicin
b) Nitrofuratoin
c) Cephalexin
d) Carbenicillin
e) Chloramphenicol.
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)
Student should know:
1. Mechanism of action, pharmacology/pharmacokinetics, side-effects of glucocorticoids.
2. Mechanism of action, pharmacology/pharmacokinetics, side-effects of immunomodulates drugs.
3. Mechanism of action, pharmacology/pharmacokinetics, side-effects of antihypertensive drugs
4. Mechanism of action, pharmacology/pharmacokinetics, side-effects of anticoagulations.
5. Mechanism of action, pharmacology/pharmacokinetics, side-effects of antiagregantions.
Student should be able to:
1. To prescribe dietary, medical and physiotherapeutic treatment of the glomerulonephritis due to their phase and concomitant diseases.
2. To prescribe dietary, medical and physiotherapeutic treatment of the nephrotic syndrome due to the form of the underlining disease.
3. To prescribe dietary, medical and physiotherapeutic treatment of the renal arterial hypertension due to the form of the underlining disease
Correct answers of test evaluations and situational tasks:
Multiple Choice Questions : 1 – C ; 2 – D; 3 – A; 4 – A; 5 – E; 6 – A; 7 – E; 8 – C; 9 – D; 10 – D.
Real-life situations. The correct answer are:
1. Urine culture followed by immediately parenteral administration of antibiotics for 10 to 14 days, followed by oral administration until all signs of renal inflammation remit.
2. c – Patients with acute renal failure are frequently treated with antibiotics for concomitant infections. Aminoglycoside antibiotics as gentamicin may be ototoxic in patients with acute renal failure; however, as the drugs are depleted by dialysis, dosage supplementation after dialysis may be necessary to maintain adequate body stores.
Nitrofurantoin is ineffective in patients with renal failure; in addition, a drug metabolite can accumulate and cause peripherial neuritis.
To treat a urinary tract infection in patients with renal failure, cephalexin is useful. Alternatives are ampicillin and trimethoprim-sulfamethoxazole. In usual dosages, these drugs achieve adequate urinary concentrations despite the low glomerular filtration rate. Carbenicillin has 4.8 meq of sodium per gram and may cause edema if given without dosage reduction to a patient with acute renal failure. Furthermore, accumulation of any penicillin may produce seizures.
References.
A – Basic:
1. Davidson’s Principles and practice of medicine (21st revised ed.) / by Colledge N.R., Walker B.R., and Ralston S.H., eds. – Churchill Livingstone, 2010. – 1376p.
2.
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 patients with nephrotic syndrome.
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. Gusak S.R.
Methodical instruction was discussed and adopted at the Department sitting “
Methodical instruction was adopted and reviewed at the Department sitting 25.06.2013, protocol № 17
