foreign students' Faculty
MODULE 2. PRINCIPLES OF INTERNAL
MEDICINE (cardiology, rheumatology, nephrology, common questions of
internal medicine)
Content
module 2. Principles of diagnosis, management and prevention of
main musculoskeletal disorders
LESSON ¹ 3 (PRACTICAL – 6 HOURS)
Theme 14. Rheumatoid arthritis. Reactive arthritis.
Aim: - to develop skills and to acquire experience relevant to management of
rheumatological patients, in particular those with rheumatoid arthritis
(RA) and reactive arthritis
(ReA).
Professional orientation
of students. Rheumatoid arthritis is a chronic inflammatory
disease characterized by uncontrolled proliferation of synovial tissue and a wide
array of multisystem comorbidities.
Prevalence is estimated to be 0.8 percent worldwide, with women twice as likely
to develop the disease as men. Untreated,
20 to 30 percent of persons with rheumatoid arthritis become permanently work-disabled within two to
three years of diagnosis. Genetic
and environmental factors play a role in pathogenesis.
Although laboratory testing and imaging
studies can help confirm the diagnosis and track
disease progress, rheumatoid
arthritis primarily is a clinical diagnosis
and no single
laboratory test is diagnostic. Complications
of rheumatoid arthritis may begin to develop within months of presentation;
therefore, early referral to or consultation with a rheumatologist for
initiation of treatment with disease-modifying antirheumatic
drugs is recommended. Between 1 and
2% of patients with non-specific
urethritis seen at clinics for
sexually transmitted diseases have reactive
arthritis and there is a similar
incidence following outbreaks of shigellosis.
A male with HLA-B27 runs a
20% risk of getting reactive
arthritis following an attack of shigella
dysentery. Although predominantly a disease of young men, the apparent 50:1 male to female ratio is
spuriously high, as urethritis is
frequently ignored in women and
children.
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.
·
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 and pathophysiology issues of RA,
ReA.
2. Classification of RA, ReA.
3. Main clinical findings of RA, ReA.
4. Main laboratory and instrumental findings
of RA, ReA.
5. Management strategies: principles of
choice of the right strategy of RA, ReA.
6. Drug therapy: indications and
contraindications of RA, ReA.
10 multiple choice tests
Multiple Choice Questions
1.
Choose
the correct answer/statement
2.
A 22-yr-old
male soldier presents with a 2-week history of a swollen right knee,
conjunctivitis and arthritis. Choose the most likely diagnosis from the below
list of options.
A. Ankylosing spondylitis
B. Reactive arthritis
C. Osteoarthritis
D. Gout
E. Psoriatic arthritis
3.
A 15-yr-old
boy complains of pain in the temperomandibular joint
for 3 months. On examination, the SHO in A&E notices micrognathia,
loss of neck extension and unequal lengths of the boy's lower limbs. Tests for
rheumatoid factor were negative. Choose the most likely diagnosis from the
below list of options.
A. Gout
B. Still's disease
C. Pseudogout
D. Rheumatoid arthritis
E. Osteoarthritis
4.
A 36-yr-old
lady presented with swollen tender knee joints. She says they feel stiff
especially in the mornings. On examination she was found to have splenomegaly,
a temperature of 38°Cand ulcerated lower limbs with Hb—9
g/dl. WBC and platelets were decreased. Albumin was 20 g/l. Choose the most
likely diagnosis from the below list of options.
A. Gout
B. Still's disease
C. Felty's syndrome
D. Rheumatoid arthritis
E. Osteoarthritis
5.
A 29-yr-old
homosexual male presented to A&E with a markedly swollen and tender left
knee. He says it's been present for about a month but has only recently become
painful. He admitted losing weight and on examination a temperature
of 38°C was found. He had no other complaints apart from a 2-month
history of cough, which he attributed to his heavy smoking. Choose the most
likely diagnosis from the below list of options.
A. Rheumatoid arthritis
B. Osteoarthritis
C. Reiter's syndrome
D. Infective arthritis
E. Felty's syndrome
6.
Choose
the most likely diagnostic antibody for Rheumatoid arthritis from the below
list of options.
A. Antimicrosomal antibody
B. Antireticulin antibody
C. Anti-dsDNA
D. P-ANCA antibody
E. Rheumatoid factor
7.
A 31-yr-old
travel agent presents with painful knees, red eyes and dysuria. He has just
returned from a trip to
A. Polyarteritis nodosa
B. Giant cell arteritis
C. Rheumatoid arthritis
D. Ankylosing spondylitis
E. Reiter's syndrome
8.
A 77-yr-old
woman with long-standing rheumatoid arthritis presented with fever and dysuria.
Her past history included recurrent chest and urinary infections. On
examination she was hyperpigmented and emaciated. Her
hands and feet were severely deformed. Abdominal examination revealed
splenomegaly but no hepatomegaly or lymphadenopathy. Choose the most likely
diagnosis from the below list of options.
A. Gout
B. Still's disease
C. Felty's syndrome
D. Rheumatoid arthritis
E. Osteoarthritis
9.
A 44-yr-old
woman presents with stiff, sausage-shaped fingers and MCP joint swelling worse
in the morning. Choose the most likely diagnostic antibody for the disease from
the below list of options.
A. Antimicrosomal antibody
B. Antireticulin antibody
C. Anti-dsDNA
D. P-ANCA antibody
E. Rheumatoid
10.
A 20-yr-old
man presents with urethitis and a painful swollen
knee. Choose the most likely diagnosis from the below list of options.
A. Rheumatoid arthritis
B. Reactive arthritis
C. Osteoarthritis
D. Haemochromatosis
E. Gonococcal arthritis
11.
A 25-yr-old
man presents with urethritis, conjunctivitis and a swollen left knee. Choose
the most likely diagnosis from the below list of options.
A. Reiter's syndrome
B. Psoriatic arthropathy
C. Osteoarthritis
D. Haemochromatosis
E. Gonococcal arthritis
Real-life situations to be solved:
2 real-life situation to be solved
1. A 35-yr-old woman has pain and stiffness in her hands, wrists, elbows,
knees and ankles. There is swelling of her MCP joints bilaterally. There is a
nodule on her left elbow. What is the most
likely diagnosis ?
2. A young man complains of red and sore eyes, painful urination
and low back pain. Three months ago he had UTI and was successfully treated for
it. What is the most likely diagnosis?
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:
Students should be able to:
1. Perform a clinical exam of cardiovascular
patients of RA.
2. Reveal main clinical syndromes of RA.
3. Draft a plan of laboratory and instrumental evaluation of cardiovascular patients of RA.
4. Assess the results of laboratory and instrumental evaluation of RA.
5. Diagnose the condition and formulate the
diagnosis according to current classification of RA.
6. Perform differential
diagnosis of RA.
7. Prescribe the appropriate therapy of
RA.
1. Perform a clinical exam of cardiovascular
patients of ReA.
2. Reveal main clinical syndromes of ReA.
3. Draft a plan of laboratory and instrumental evaluation of cardiovascular patients of ReA.
4. Assess the results of laboratory and instrumental evaluation of ReA.
5. Diagnose the condition and formulate the
diagnosis according to current classification of ReA.
6. Perform differential
diagnosis of ReA.
7. Prescribe the appropriate therapy of ReA.
Correct
answers of test evaluations and situational tasks:
Multiple Choice Questions.
1- B, 2- D, 3- D, 4- C, 5- E, 6- E, 7- C, 8- E, 9- B, 10- A.
Real-life situations.
The correct answer is
1. Rheumatoid arthritis.
2. Reiter's syndrome.
References.
À – 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. – 1376 p.
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) http://intranet.tdmu.edu.ua
: Rheumatoid
Arthritis. Reactive arthritis
c) http://emedicine.medscape.com/
d) http://meded.ucsd.edu/clinicalmed/introduction.htm
B – Additional:
1. Clinical Rheumatology (The
Clinical Medicine Series) 12 edition/ Pacific Primary Care Software PC/ M.D., C.
G. Weber.- 2011.-p.526 .
2. Kelley's Textbook of Rheumatology, 9th
Revised edition / Firestein, Gary S.; Budd, Ralph C.;
Gabriel, Sherine E.; O'Dell, James R.; McInnes, Iain B.-2012.-p. 2292.
3. Rheumatoid Arthritis/ Smolen,
Josef S.; Kalden, Joachim R.; Maini,
Ravinder N. -2012. - 424 pages.
Methodical instruction was been worked out by:
Prof. S.I.Smiyan “
Methodical instruction was adopted and reviewed at the Department sitting 15.06.2009, Minute ¹ 2
Methodical
instruction was adopted and reviewed at the Department sitting 29.06.2010, Minute ¹ 19
Methodical
instruction was adopted and reviewed at the Department sitting 16.06.2011, Minute ¹ 13
Methodical
instruction was adopted and reviewed at the Department sitting 12.06.2012, Minute ¹ 12
Methodical
instruction was adopted and reviewed at the Department sitting 25.06.2013, Minute ¹ 17