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 4 (PRACTICAL – 6 HOURS)

 

Theme15.  Osteoarthritis. Gout.

 

Aim: to  learn  diagnosing and treatment of  Osteoarthritis  and Gouty arthritis

Professional orientation of students: Rheumatic  diseases  are  extremely  widening.  From  1 %  to  3 %  of  people  in  Europe  and  America  suffer  from  some  form  ofthe  joint  disease.  Arthritis  can  be  present  in  the  number  of  specifically  identifiable  conditions  exceeds  100,  that  cause  pain  in  the  joints  and  connectivetissues.  It  is  necessary  performing  the  differential  diagnosis  of  arthritis,  because  joint  symptoms  present  not  only  in  inflammatory  arthritis,  degenerativejoint  disease,  but  may  be  part  of  a  systemic  disease.  If  you  can  make  a  diagnosis  early  in  your  patient  you  may  be  able  to  forestall,  reduce  or  evenprevent  entirely  some  of  the  more  severe  or  debilitating  complications  seen  with  those  disorders.  Establishment  of  the  correct  diagnosis  makes  itpossible  to  order  an  appropriate  treatment.  Osteoarthritis,  the  most  common  form  of  joint  disease,  is  chiefly  a  disease  of  aging.  Ninety  percent  of  allpeople  have  radiographic  features  of  osteoarthritis  in  weight-bearing  joints  by  age  40.  Symptomatic  disease  also  increases  with  age.  This  arthropathy  is 

 

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 follow up 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 there late 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.

·                  Monitorresponsetotherapy.

 

Seminar discussion of the pratical issues

1.      Examination of the patient with OA.

2.      Call syndromes for OA and to do differential diagnosis of OA.

3.      Evaluate dates of additional methods of investigations for diagnosis of OA.

4.      Make full diagnosis of OA.

5.      Make plan of examination of patient with OA.

6.      Prescribe the treatment of the OA

7.      Examination of the patient with Gout.

8.      Call syndromes for Gout and to do differential diagnosis of Gout.

9.      Evaluate dates of additional methods of investigations for diagnosis of Gout.

10.      Make full diagnosis of Gout.

11.        Prescribe the treatment of the Gout.

 

Test evaluation and situational tasks.

10 multiple choice tests

Multiple Choice Questions

Choose the correct answer/statement

1.                      A 70-yr-old fit farmer presents with pain on weight bearing and restricted movements of the right hip.  Choose the most likely diagnosis from the below list of options.

A.      Ankylosing spondylitis

B.      Erythema nodosum

C.      Osteoarthritis

D.      Gout

E.        Psoriatic arthritis

2.          An elderly  man started frusemide 4-weeks ago and now presents with a red, hot, swollen first metatarsal phalangeal joint.  Choose the most likely diagnosis from the below list of options.

A.      Ankylosing spondylitis

B.      Joint sepsis

C.      Osteoarthritis

D.      Gout

E.        Psoriatic arthritis

3.                      A 50-yr-old woman complains of redness, swelling and stiffness in the distal interphalangeal joints of her hands, but has  no other joint complaints.  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 55-yr-old woman complains of stiffness in her fingers worse at the end of the day. The DIP joints and the first  metacarpophalangeal joints are affected.  Choose the most likely diagnosis from the below list of options.

A.      Osteoarthritis

B.      Rheumatoid arthritis

C.      Psoriatic arthropathy

D.      Haemochromatosis

E.        Gonococcal arthritis

5.                      A 68-yr-old woman complains of arthritis in the fingers and big toe. On examination she has bony swellings of the first  carpometacarpal joint and the distal interphalangeal joints and has an affected metatarsophalangeal joint.  Choose the most likely diagnosis from the below list of options.

A.      Rheumatoid arthritis

B.      Hyperparathyroidism

C.      Psoriatic arthropathy

D.      Osteoarthritis

E.        Haemochromatosis

6.                      An 67-yr-old man presents with a red, warm swollen metatarso-phalangeal joint following a right total hip replacement  operation.  Choose the most likely diagnosis from the below list of options.

A.      Ankylosing spondylitis

B.      Reactive arthritis

C.      Osteoarthritis

D.      Acute Gouty arthritis

E.        Psoriatic arthritis

7.                      A 58-yr-old alcoholic man presents with a hot swollen first metatarsophalangeal joint and a lesion on the rim of the right  pinna.  Choose the investigation for diagnosis from the below list of options.

A.      HLA-B27

B.      Synovial fluid analysis

C.      X-ray

D.      Anti-dsDNA antibody

E.        Rheumatoid factor

8.                      A 60-yr-old man has started chemotherapy for lymphoma. He has developed a painful swollen hot right knee. He is  apyrexial.  Choose the most likely changes from the below list of options.

A.      High ESR

B.      Erosions on X-ray

C.      Positive blood culture

D.      Positive rheumatoid factor

E.        Urate crystals on joint aspirate

9.          A 53-year-old male is evaluated because of pain in the left inguinal area, lower back, and hands. The inguinal pain worsens as he walks, and all pain increases as the day progresses. On physical examination, internal rotation of the left hip elicits the groin pain. The second, third, and fourth metacarpophalangeal joints are swollen, warm, and tender to pressure. Radiographs show severe osteoarthritis in the left hip. Which of the following is the best test to confirm the diagnosis?

A.      Rheumatoid factor

B.      HLA-B27

C.      Serum iron and iron-binding capacity

D.      Fasting plasma glucose

E.        Serum uric acid

10.            Which of the following is a sign for Gouty arthritis?

A.      Simultaneous involvement of the same joint areas on both sides of the body.

B.      Acute arthritis of first metatarsophalangeal joint

C.      Symmetric sacroilitis

D.      Asymmetric sacroilitis

E.        Positive RF

 

Real-life situations to be solved:

Real-life situations.

1. A  54-year-old women complains of night pain in knees, starting stiffness, limitation of motion range. General state became worse a week ago after cooling. She has been ill through 5 years.  Polyarthralgias  started when the menstruation stopped. She didn’t receive any treatment. Objectively: General state is satisfactory. AP – 130/75 mm Hg, pulse is 78 beats per minute. Cardiovascular and respiratory systems are normal. Abdomen is soft, liver isn’t palpated. Knees are  deformated, skin and local temperature are normal, the motion of knees is limited for 15°. Blood analysis: L –6,4´109/l, ESR  11 mm  per hour, CRP - -,  sialic  acid – 0,180. X-ray examination of joint – unequal loss of joint space,  osteophytes. Questions: What is the diagnosis?

2.  An elderly man started  frusemide  2-weeks ago and now presents with a red, hot, swollen first metatarsal  phalangeal  joint.  General blood analysis : L -12000; ESR is 20 mm/hour. Biochemical blood analysis: CRP - (++); uric acid 0/540  mmol/l, ALT 0,320, AST 0,430 ,  bilirubin  15  mmol/l. What is the preliminary 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.                 Etiology, pathogenesis of  Osteoarthritis.

2.                 Clinical manifestations of  Osteoarthritis.

3.                 Clinical classification of  Osteoarthritis.

4.                 Principles and methods of  Osteoarthritis  treatment and prophylaxis.

5.                 Etiology, pathogenesis of Gout.

6.                 Clinical manifestations of Gouty arthritis.

7.                 Clinical manifestations of internal organs involvement in Gout.

8.                 Clinical classification of Gouty arthritis.

 

Students should be able to:

1.                 History taking and physical examination of the patients with osteoarthritis  .

2.                 Syndromes in OA and Gouty arthritis making differential diagnosis of Osteoarthritis.

3.                 Interpret data of laboratory and instrumental methods of examination  in osteoarthritis.

4.                 Make full diagnosis of osteoarthritis.

5.                 Make plan of examination of patient with osteoarthritis.

6.                 Prescription of the treatment of the osteoarthritis.

7.                 Evaluate prognosis for patient with osteoarthritis  and gouty arthritis.

8.                 History taking and physical examination of the patients with Gouty arthritis.

9.                 Syndromes in OA and Gouty arthritis making differential diagnosis of Gouty arthritis.

10.             Interpret data of laboratory and instrumental methods of examination  in Gouty  arthritis  .

11.             Make full diagnosis of Gouty arthritis.

12.             Make plan of examination of patient with Gouty arthritis.

13.             Prescription of the treatment of the Gouty arthritis

14.            Evaluate prognosis for patient with Gouty arthritis.

 

Correct answers of test evaluations and situational tasks:

Multiple Choice Questions. 1 –  Ñ. 2 – D. 3 -A. 4-A .  5-C. 6-A. 7-A. 8-A. 9-D. 10-B

The correct answer is

1. Primary osteoarthritis.

2.  Acute gouty arthritis

 

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.    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 : Osteoarthritis. Gout.

b)      www.eular.org

c)     www.rheumatology.org

d)      http://emedicine.medscape.com/ 

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.  Fast Facts: Osteoarthritis, 2 edition / Philip G.; Ph.D. Conaghan , Amanda E., M.D. Nelson; Health Pr.- 2012.-p. 112

4.  Medifocus Guidebook on: Osteoarthritis of the Knee / Elliot Jacob PhD ; CreateSpace Independent Publishing Platform. - 2012.- p.174 .

5.  Gout: Causes, Symptoms, Signs, Diagnosis and Treatments, Revised Edition/    S. Smith.;U.S.  Department of Health and Human Services.; National Institutes of Health.; National Institute of Arthritis and Musculoskeletal and Skin Diseases.;/ CreateSpace Independent Publishing Platform;.- 2012.-p. 40.

6. Gout & Kidney Stones Causes Exposed / Dr Noreen Picken BA DC.;/ Dr Noreen Picken; 1 edition.- 2012.-p.60.

 

 

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