METHODICAL INSTRUCTION FOR STUDENTS OF THE 5 COURSE

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.

 

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 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.

Test evaluation and situational tasks.

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 Spain. Choose the most likely diagnosis from the below list of options.

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:

  1. Relevant terminology, definitions and classifications of RA.
  2. Chief complaints of cardiac patients of RA.
  3. Evaluation of basic signs and symptoms of RA.
  4. Specific signs and symptoms of RA.
  5. Methods of physical examination of RA.
  6. Methods of laboratory evaluation of RA.
  7. Methods of instrumental evaluation of RA,.
  8. Specific signs and symptoms of ReA.
  1. Methods of physical examination of ReA.
  2. Methods of laboratory evaluation of ReA.
  3. Methods of instrumental evaluation of  ReA.
  4. Principles of management of ReA.

 

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.

ÀBasic:

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. Harrison’s principles of internal medicine (18th 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)                  http://intranet.tdmu.edu.ua : Rheumatoid Arthritis. Reactive arthritis

a)                 www.eular.org

b)                www.rheumatology.org

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.Smiyan28” August, 2013.Minute ¹ 1

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