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Methodological instructions to the Lesson ¹ 4

June 1, 2024

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 № 4 (PRACTICAL – 6 HOURS)

Theme 21: Acute and chronic renal failure

Aim: is to learn clinical, laboratory, instrumental signs and symptoms and in its treatment depending on stages ofchronic renal failure.

Professional orientation of students: Although the exact incidence of CRF at its different stages is unknown, ESRD 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. Pathophysiology of the acute and chronic renal failure.

2. Causes of the acute and chronic renal failure.

3. Clinical manifestations of the acute and chronic renal failure.

4. Peculiarity clinical manifestations of the CRF due to disease.

5. K+ disorder in patients with renal failure.

6. Calcium abnormalities in patients with renal failure.

7. Hematologic abnormalities in patients with renal failure.

8. Stage of the CRF.

9. Classification of the acute renal failure.

10. Treatment of the CRF.

11. Dietotherapy.

12. Correction of the electrolytes abnormalities.

13. Indications and contraindications to hemodyalisis.

14. Transplantation of the human kidney.

15. Immunosuppressive treatment.

Test evaluation and situational tasks.

Choose the correct answer/statement:

1. Which of the following forms of acute renal failure is a hyper catabolic?

A. Medicinal

B. Post-renal

C. In patients with prolonged compression syndrome

D. Prerenal

E. Hepato-renal syndrome

2. What symptom is not typical for acute renal failure:

A. Acute onset

B. Oliguria

C. The reduced size of the kidneys

D. hyperkalemia

E. Collapse

3. Please mark common complication of acute renal failure:

A. Аrterial hypertension

B. Hypokalemia

C. Acute Bacterial Infection

D. Congestive heart failure

E. Secondary hyperparathyroidism

4. Please mark an early sign of chronic renal failure (CRF):

A. Metabolic acidosis

B. Hypercalcemia

C. Nocturia

D. Azotemia

E. Reducing the size of the kidneys

5. Please mark the main cause of death in patients on hemodialysis:

A. Acute viral hepatitis

B. Acute bacterial pneumonia

C. Cardiovascular Disease

D. Cancer

E. The dialysis amyloidosis

6. Select the indications for urgent referral of patients with chronic renal failure on hemodialysis:

A. Metabolic acidosis

B. Severe oliguria

C. Anasarca

D. High hyperkalemia

E. Severe hypertension

7. Which antihypertensive drug can be used in patients with chronic renal failure?

A. Hypothiazid

B. Pentamin

C. Korinfar

D. Dopegit

E. Verospiron

8. Which of these drugs can be used in patients acute or chronic renal failure?

A. Furadonin

B. Nevigramon

C. Ampicillin

D. Sulfadimethoxine

E. Tetracycline

9. Please mark the pre-renal causes of acute renal failure

A. Increasing cardiac output

B. Dehydration

C. Hypervolaemia

D. Vascular collapse

E. Hypertensive crisis

10. Please mark common causes of anemia in chronic renal failure:

A. Iron deficiency

B. Deficiency of vit. B-12 and folic acid

C. Chronic hemolysis

D. Reducing the synthesis of erythropoietin

E. Chronic intoxication with aluminum

11. Choose the complications of EPO therapy of the dialysis patients:

A. Acute vascular insufficiency

B. Acute encephalopathy

C. Hypercalcemia

D. Worsening of hypertension

E. Hyperkalemia

12. Select the most typical forms of CKD bone lesions:

A. Hyperparathyroid osteodystrophy

B. Osteoporosis

C. Aluminum osteodystrophy

D. Aseptic necrosis of the femoral heads

E. Aplastic osteodystrophy

13. Please mark the methods of prevention of uremic hyperparathyroidism:

A. Enrichment of phosphorus diet

B. Enrichment of the diet with calcium

C. Application phosphate binders

D. Application of calcium, vitamin D3

E. The use of calcitonin

Real-life situations to be solved:

1. A 50-year-old man with end-stage chronic glomerulonephritis is maintained on long-term hemodialysis three times each week. He now comes to the dialysis unit with a 4,5 kg weight gain since his last dialysis 2 days ago. He is moderately short of breath and his blood pressure is 195/125 mm Hg. What would be the most appropriate management of his blood pressure at this point?

2. Describe the types of glomerular lesions in postinfectious glomerulonephritis due to group A streptococcus and crescentic glomerulonephritis.

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, classification of acute and chronic renal failure.

2. Principles of the dietary in the acute and chronic renal failure.

3. Principles of the treatment of the acute and chronic renal failure.

Students should be able to:

1. Put diagnosis of the acute and chronic renal failure

2. Prescribe treatment for patients with acute and chronic renal failure

3. Give emergency therapy for patient with acute renal failure.

Correct answers of test evaluations and situational tasks:

Multiple Choice Questions: 1. C; 2. C; 3. C; 4. C; 5. C; 6. D; 7. C; 8. C; 9. B,D; 10. A,D,E; 11. B,D,E; 12. A,C,E; 13. B,C,D.

Real-life situations. The correct answer are: 1. Hypertension in the course of end-stage renal failure is usually related to an increase in extracellular fluid volume. The best management is the expeditious removal of fluid by ultrafiltration dialysis. Such treatment usually results in normalization of the blood pressure and relief of circulatory congestion.

2. Postinfectious glomerulonephritis is associated with rapid improvement in glomerular filtration rate, apparently owing to reduction in glomerular capillary edema; most persons affected recover completely within several years. Chronic glomerulonephritis is characterized by slow progressive deterioration of renal function. Crescentic glomerulonephritis is usually associated with rapidly progressive deterioration of glomerular filtration rate over a few weeks to months; when associated with pulmonary hemorrhage, it is called Goodpasture’s syndrome.

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: Acute and chronic renal failure

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.