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.
·
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.
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.
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
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.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