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.
·
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.
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
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.
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.
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.
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.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