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 № 3 (PRACTICAL – 6 HOURS)

 

Theme 20: Pyelonephritis

 

Aim: To learn the etiology pathogenesis, clinical findings, differential diagnosis, complications, it treatment, and prognosis of acute and chronic pyelonephritis.

Professional orientation of students: Diseases affecting the kidney or the lower urinary tract can often be detected, even in asymptomatic patients, from clues derivated from routine clinical and laboratory examination. Physician have long appreciated that specific lesion of the urinary tract frequently give rise to a consistent array of clinical sign, symptoms, and laboratory findings which, when taken together, constitue syndromes that effectively narrow the range of causal entities to be considered  in the search for an exact diagnosis pathology. Nephrological syndromes have been recognized by routine evaluation instead usually must required additional urology evaluation, that is why it is so necessary to know the clinical symptoms, laboratory investigation and treatment of this pathology.

 

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.                Urine sediment changes in patients with pyelonephritis.

2.                Clinical features of acute and chronic pyelonephritis

3.                Laboratory diagnostic methods of pyelonephritis

4.                Instrumental diagnostic methods of pyelonephritis.

5.                Differential diagnosis of pyelonephritis.

6.                Treatment of the acute and chronic pyelonephritis.

7.                Antibiotics and uroseptics in treatment of the acute and chronic pyelonephritis.

8.                NSAIDs in treatment of the acute and chronic pyelonephritis.

9.                Treatment of the local hemodynamic disorders.

10.           Preventation of the recurrence of the chronic pyelonephritis.

11.           Phytotherapy of the acute and chronic pyelonephritis.

12.           Prophylactic medical examination and sanatorium-resort therapy in the renal disorders.

 

Test evaluation and situational tasks.

Choose the correct answer/statement:

1.                Which provisions about pyelonephritis are correct?

A.              Much more common in men than in women

B.               Often develops in childhood

C.                Occurs on the basis of impaired passage of urine

D.               Often develops during pregnancy

E.                Often arises in patients with congestive heart failure

 

2.                Which organisms are the most common pathogens of pyelonephritis?

A.               E. coli

B.                Enterococcus

C.                Proteus

D.               pnevmotsisty

E.                mycobacteria

 

3.                What factors contribute to the persistence of the pathogen in the urinary tract and chronicity of pyelonephritis?

A.               Presence of protoplasts and L-forms

B.               The phenomenon of bacterial adhesion

C.                “Physiological” obstruction of the urinary tract

D.              Synthesis of urinary antibodies

E.               polyuria

 

4.                What factors are significantly make heavier duration of acute pyelonephritis and may significantly worsen the prognosis?

A.              Proteus as the agent process

B.               Stafilococcus aureus which is coagulated plasma as a causative agent of the process

C.               Ascendant urinogenic route of infection

D.              Acute occlusion of the urinary tract

E.               Hyperuricemia

 

5.                What is the sign of pyelonephritis distinguishes it from other interstitial renal lesions?

A.               Tubular dysfunction in violation of the acidification of urine

B.               Resistant hypertension

C.               Edema and neutrophil infiltration of the renal pelvis

D.              The development of “the kidney, which is losing salt” with hypotension

E.               Infiltration of lymphocytes and histiocytes, and sclerosis of the renal pelvis

 

6.                What drugs should not be prescribed in pyelonephritis in CKD stage?

A.              Aminoglycosides

B.               Oxacillin

C.               Erythromycin

D.              Polymyxin

E.               carbenicillin

 

7.                Which of these diseases rarely leads to the development of pyelonephritis?

A.              Diabetes mellitus

B.               Using of hormonal contraceptives

C.               Rheumatoid arthritis

D.              Pregnancy

E.               Prostatitis

 

8.                Patient 28 years old, a kindergarten teacher 4 years ago, during the second half of pregnancy, were first discovered proteinuria, leukocyturia, red blood cell. After delivery, analyzes of urine normal. About 2 weeks ago, after suffering flu there were strong pain in the lumbar region on the right, radiating to the groin, frequent painful urination, chills, fever up to 39 C. In outpatient examination revealed proteinuria 0.125 g/l, leucocyturia 25-30 in sight, erytrotsyturiya 8-10 in sight, the specific gravity of urine 1016. In blood leukocytes 13,6×10⁹/L ESR-30 mm/hour. Assigned erythromycin therapy at a dose of 1 g per day did not give a significant effect, although the temperature dropped to subfebrile. Therapy with spasmolytics also was ineffective.

8. I. Please indicate the most likely diagnosis:

A.              Acute pyelonephritis

B.               Exacerbation of chronic pyelonephritis

C.               Urolithiasis, complicated pyelonephritis

D.              Chronic glomerulonephritis latency flow in the acute stage

 

8. П. The most informative studies for the diagnosis of renal function are:

A.              Excretory urography

B.               IUltrasonography

C.               A kidney biopsy

D.              Cystochromoscopy

E.               Urine culture

F.                Zimnitsky test

 

8. III. Treatment of the patient should include:

A.              restoration of the passage of urine (abundant drink, if necessary ureter catheterization, surgery)

B.               antibacterial agents. Select from those listed in the most effective case:

a.                 semisynthetic penicillins

b.                cephalosporins

c.                 gentamicin

d.                biseptol

e.                 furagin

 

8. IV. What is the cause of treatment failure:

A.              Incorrect diagnosis

B.               Wrong choice of drug

C.               Inadequate dose

D.              Inability of antibiotic therapy due to intolerance to many antibiotics

 

Real-life situations to be solved:

1. A 19-year-old woman is evaluated for the sudden onset, in right lower quadrant, of constant pain that is accentuated by deep inspiration. She has tenderness on deep palpation of the both flanks. Temperature is 38,5 ° C; blood leukocyte count, 18500/mm²; urinalysis re­veals 30 to 40 WBCs per high-power field and numerous gram-negative bacteria. What is the most appropriate initial management for this patient?

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)

 

Students should know:

1. Modern views of the etiology, pathogenesis of pyelonephritis

2. Classification of pyelonephritis

3. Clinical, laboratorial findings of acute and chronic pyelonephritis

4. Differential diagnosis of acute and chronic pyelonephritis

5. Treatment of  pyelonephritis

6. Clinical findings, complications, treatment of chronic pyelonephritis

7. Mechanism of action, pharmacology/pharmacokinetics, side-effects of antibiotics.

8. Prognosis for short and long term.

 

Students should be able to:

1. Put diagnosis of the acute and chronic pyelonephritis

2. Prescribe treatment for patients with acute and chronic pyelonephritis

3. Carry out differential diagnosis of acute and chronic pyelonephritis.

 

Correct answers of test evaluations and situational tasks:

Multiple Choice Questions: 1. B,C,D; 2. A,B,C; 3. A,B,C; 4. A,B,D; 5. C,E; 6. A,E; 7. B,C; 8.І. В; 8.ІІ. A,B,E,F; 8.III. A,Ba,b; 8.IV. B

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. 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 (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: Pyelonephritis

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 12.06.2012. Minute № 12

Methodical instruction was adopted and reviewed at the Department sitting 25.06.2013, protocol № 17