METHODICAL INSTRUCTION FOR STUDENTS OF THE 6 COURSE

foreign students'Faculty

MODULE 3. Current practice in internal medicine.

Content module 2. «Management of patients with musculoskeletal disorders.   »

 

LESSON ¹ 3 (PRACTICAL – 6 HOURS)

 

Theme 9. Management of patients with the systemic connective tissue diseases (systemic lupus erythematosus (SLE), systemic sclerosis (SS), dermatomyositis (DM) and polymyositis (PM).

 

Aim: -  to develop skills and to acquire experience relevant to management of patients with rheumatological diseases, in particular those with systemic connective tissue diseases : systemic lupus erythematosus (SLE), systemic sclerosis (SS), dermatomyositis (DM) and polymyositis (PM), determination of degree of loss of capacity, to appoint the differentiated treatment-depending on the form of collagenases, his flow and degree of activity.

Professional orientation of students. concordantly given to the state statistical accounting, in the last few years there is substantial growth of the indicated forms of pathology in Ukraine. So, for example, prevalence Systemic lupus erythematosus (SLE) was increased from 48 to 100 thousands of population in 1967 to 92 on 100 thousands of population in 1995. The characteristic morphological sign of collagenases is making progress disorganization of connecting tissue with an in drawing in the pathological process of vessels, which shows up in a clinic the defeat of many organs and systems, making progress character of motion, rapid origin of temporal and proof loss of capacity. Base and symptomatic therapy of collagenosess is correctly neat instrumental in the maintenance of capacity of patients, improvement of quality of their life and diminishing of social charges of society on maintenance of patients with the proof loss of capacity.

 

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 of  SLE, SS, DM, PM.

2. Classification of  SLE, SS, DM, PM.

3. Main clinical findings of  SLE, SS, DM, PM.

4. Main laboratory and instrumental findings of  SLE, SS, DM, PM.

5. Management strategies: principles of choice of the right strategy of  SLE, SS, DM, PM.

6. Drug therapy: indications and contraindications of  SLE, SS, DM, PM.

 

 

Test evaluation and situational tasks.

Choose the correct answer/statement

1.  The best drug to treat SLE is :

A.  Asprin

B.  Indomethacin

C.  Prostoglandines

D.  Procainamide

E.  Steroids

2.  Drug-induced systemic lupus erythematosus (SLE) can be characterized by all of the following statements EXCEPT?

A.  Twenty percent of patients receiving procainamide develop drug-induced lupus

B.  Most patients on hydralazine develop a positive antinuclear antibody (ANA) test; however, only 10 percent suffer from lupuslikesymptoms

C.  If patients with drug-induced lupus fail to respond within several weeks of discontinuing the offending agent, a trial of corticosteroids is indicated

D.  If a patient with drug-induced lupus has persistent symptoms for longer than 6 months, an anti-ds antibody

E.  None of the above

3.  For the Systemic lupus erythematosus choose the most likely diagnostic antibody from the below list of options.

A.  Antimicrosomal antibody

B.  C-ANCA

C.  Anti-dsDNA

D. Antiparietal cell antibody

E.  Antiacetylcholine receptor antibody

4.   For the Systemic lupus erythematosus choose the most likely diagnostic antibody from the below list of options.

A.  Antimicrosomal antibody

B.   C-ANCA

C.   Antinuclea antibody

D.  Antiparietal cell antibody

E.   Antiacetylcholine receptor antibody

5.      The bad prognostic indicator for scleroderma is:

A.  Renal involvement

B.  Goose skin appearance

C.   Oedema legs

D.  Widening of pulse pressure

E.   Calcification

6.   Which of the following is a typical immune complex disease?

A.  Osler-Weber-Rendu syndrome

B.   Urticaria pigmentosa

C.  Lupus erythematosus

D.  Gastric ulcer

E.   Pneumonia

7.   Which of the following autoantibodies is more likely to be found in patients with systemic sclerosis?

A.  Anti-Smith (anti-Sm)

B.  Anti-ribonucleoprotein (RNP)

C.  Anti-DNA topoisomerase 1 (anti-Scl70)

D.  Anti-citrullinated peptide

E.  Anticentromere

8.  Vegetations on undersurface of A.V. valves are found in:

A.  Acute Rheumatic corditis

B.   Limban Sack's endocarditis

C.   Non thrombotic bacterial endocarditis

D.   Chronic rheumatic carditis

E.    MVP

9.   Serologic tests should be performed in patients with specific musculoskeletal complaints for assessing all the following EXCEPT:

A.  Rheumatoid factor

B.  Antinuclear antibodies (ANA)

C.  Uric acid level

D.  Total cholesterol

E.  Antistreptolysin  O (ASO) titer

10.  Which one of the following statements about autoimmune diseases is true

A.   Affect about 1 person in every 1000

B.   Are more common in women

C.  Tend to begin in early childhood

D.   Are an inevitable consequence of autoimmune responses

E.   Are usually mediated by type I hypersensitivity

Real-life situations to be solved:

2 real-life situation to be solved:

1. A 35-yr-old woman presented with arthralgia, myalgia, facial rash and blood pressure of 190/110 and impaired renal function. Urine microscopy showed scanty red cells and granular casts. Renal biopsy showed linear IgG on glomerular basement membrane. What is the most likely diagnose?

2. A 52-yr-old woman complains of a 8-month history of Raynaud's phenomenon, progressive skin tightness, thickening of fingers and hands, dyspnoea on exertion and dysphagia. Choose the most likely diagnosis from the below list of options.

 

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. General  anatomy and physiology of  SLE, SS, DM, PM.

2. Relevant terminology, definitions and classifications of  SLE, SS, DM, PM.

3. Chief complaints of  SLE, SS, DM, PM.

4. Evaluation of basic signs and symptoms of  SLE, SS, DM, PM.

5. Specific signs and symptoms of  SLE, SS, DM, PM.

6. Methods of physical examination of cardiovascular patients with  SLE, SS, DM, PM.

7. Methods of laboratory evaluation of  SLE, SS, DM, PM.

8. Methods of instrumental evaluation of of  SLE, SS, DM, PM.

9. Management principles  of  SLE, SS, DM, PM.

 

Students should be able to:

1. Perform a clinical exam of  SLE, SS, DM, PM.

2. Reveal main clinical syndromes of  SLE, SS, DM, PM.

3. Draft a plan of laboratory and instrumental evaluation of  SLE, SS, DM, PM.

4. Assess the results of laboratory and instrumental evaluation of  SLE, SS, DM, PM.

5. Diagnose the condition and formulate the diagnosis according to current classification.

6. Perform differential diagnosis of  SLE, SS, DM, PM.

7. Prescribe the appropriate therapy of  SLE, SS, DM, PM.

 

Correct answers of test evaluations and situational tasks:

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

Real-life situations. The correct answer is

1.   Lupus nephritis.

2.   Scleroderma.

 

References.

À-Basic:

11.  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 : Management of patients with the systemic connective tissue diseases

a)    www.eular.org

b)   www.rheumatology.org

c)   http://emedicine.medscape.com/

d)   http://meded.ucsd.edu/clinicalmed/introduction.htm

 

 

B-Additional:

1.  Scleroderma: From Pathogenesis to Comprehensive Management [Hardcover]/John Varga.; Christopher P. Denton.; Fredrick M. Wigley/ Springer.- 2011.-p.709.

2.  Systemic Lupus Erythematosus / Smolen, Josef S.; Zielinski, Christoph C.; Geyer, G. -2012.- p.200.

3.  Clinical Rheumatology  (The Clinical Medicine Series) 12 edition/ Pacific Primary Care Software PC/ M.D., C. G. Weber.- 2011.-p.526 .

4.  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.

 

 

 

 

 

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