foreign students' Faculty
Module 3.
CURRENT PRACTICE OF INTERNAL MEDICINE
Content module 3.
Management of patients with
disorders of gastrointestinal tract, liver and
pancreatic diseases
LESSON ¹ 2 (PRACTICAL – 6 HOURS)
Theme
12. Management
of patient with chronic diarrhea syndrome. Management of patient
with constipation
Aim:
- to develop skills and to acquire experience relevant to management of
patients with chronic diarrhea syndrome,
with constipation
Professional orientation of students. Inflammatory bowel diseases are a complex
problem of modern gastroenterology because the etiology of these diseases
remains unknown, and pathogenesis is still poorly understood. Nonspecific
ulcerative colitis (NUC) and chronic colitis (HC) are more common among people
of working age, these diseases are accompanied by many complications and lead
often to disabilities and mortality. Throughout the world, especially in
developed countries, inflammatory bowel diseases remain a major health and
social problem. Prevalence of irritable bowel syndrome (IBS) among the
population of European countries consists on the average 15-20%.
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.Features of the anatomical structure of small and large intestines.
2. Functions
of small and large
intestines.
3. Methods of examination of patients with diseases of the small and large
intestines.
4. Laboratory and instrumental diagnosis of diseases of small and large
intestines.
5. Diagnostic criteria of diseases of small and large intestines. Clinical
diagnosis of celiac disease, CD, NUC, IBS in accordance with existing
classifications.
6. Principles of treatment of diseases of small and large intestines.
7. Preventing disabilities and expertise of diseases of the small and large
intestines.
Choose the correct answer:
1. Skip granulomatous lesions of bowel are seen
in
A. Crohn's disease
B. Ulcerative colitis
C. Whipple's disease
D. Reiter's disease
E. Irritable bowel disease
2. Which of
the following is not a congenital abnormality associated with Juvenile polyps
A.
Macrocephaly
B.
Meckel's diverticulum
C.
Malrotation
D.
Mesenteric lymphangioma
E.
None of mentioned
A.
Tuberculosis
B.
Cirrhosis
C.
Malabsorption
D. Pancreatitis
E. Peptic ulcer
4.
Which of the following statements regarding eosinophilic enteritis is correct?
A.
It
may be difficult to distinguish from regional enteritis.
B.
It
affects only the small intestine.
C.
The
majority of patients have a history of food allergies or asthma.
D.
Treatment
with glucocorticoids is not indicated.
E.
Peripheral
blood eosinophilia is rare.
5. According to the USPSTF,
which modality below comprises an acceptable colon cancer screening strategy
for average-risk patients?
A.
Fecal occult blood testing (FOBT) on
three consecutive stools semi-annually.
B.
FOBT on at least five stools over 2
years.
C.
Single-contrast barium enema every 5
years.
D.
Double-contrast barium enema every 5
years.
E.
Flexible sigmoidoscopy every 7 years.
6. The most likely histological abnormality associated
with celiac sprue (gluten-sensitive enteropathy) is
A. Signet ring cells on gastric biopsy
B. Mucosal inflammation and crypt
abscesses on sigmoidoscopy
C. Villous atrophy and increased
lymphocytes in the lamina propria on small bowel biopsy
D. Small, curved gram-negative bacteria
in areas of intestinal metaplasia on gastric biopsy
E.
Edema and basal hyperplasia
7. Hyperpigmentation, hepatomegaly, polyarthritis,
hyperglycemia are the signs of
A. Insulin-dependent diabetes mellitus
B. Pancreatic carcinoma
C. Addison’s disease
D. Hemochromatosis
E. Chronic
Hepatitis C
8. Sigmoidoscopy shows inflamed, friable
mucosa from rectum to midsigmoid. What is the most likely diagnosis?
A. Ulcerative colitis
B. Crohn’s disease
C. Ischemic colitis
D. Diverticulitis
E. Amebic colitis
9. Which of the following is
the disease with "Cobblestoning"
from longitudinal and transverse ulcerations most frequently involves the small
bowel?
A. Gastro-oesophageal reflux disease
B.
Crohn's disease
C. Ulcerative
colitis
D. Irritable
bowel syndrome
E. Viral
gastroenteritis
10. As more severe Crohn's
disease develops,
aphthous ulcers don’t become
A. "collar-button" ulcers
B. enlarged
C. deeper
D.
forming
serpiginous.
E.
forming
linear ulcers
Real-life
situations to be solved:
1. A 47-yr-old agricultural
worker complains of a chronic cough, purulent sputum and abdominal distention.
He has just arrived in England from Spain where he was picking grapes. Choose
the single most likely diagnosis from the list of options above.
A.
Tuberculosis
B.
Cirrhosis
C. Malabsorption
D. Pancreatitis
E. Peptic ulcer
2. A 32-year-old
man has acute enteritis with bloody diarrhea of 1 day’s duration associated with
abdominal pain, fever, and small, frequent stools. He was previously well.
Which of the following pathogens is most likely causing this patient’s acute
illness?
A.
Campylobacter
jejuni
B. Cryptosporidium
C. Giardia lamblia
D. Helicobacter pylori
E. Acute pancreatitis
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 digestive system.
2.
Relevant terminology, definitions and classifications diseases of
large and small intestine.
3.
Chief complaints of patients with diseases
of large and small intestine.
4.
Evaluation of basic signs and symptoms in patients with diseases of large
and small intestine.
5.
Specific signs and symptoms of patients with diseases of large
and small intestine.
6.
Methods of physical examination of patients with diseases of large
and small intestine.
7.
Methods of laboratory evaluation of patients with diseases of large
and small intestine.
8.
Methods of instrumental evaluation of patients with diseases of large
and small intestine.
9.
Principles of management of patients with diseases of large
and small intestine.
Students
should be able to:
1. Perform a clinical exam of patients with pathology of large and small intestine
2. Reveal main clinical syndromes of patients with pathology of large
and small intestine
3.
Draft a plan of laboratory and instrumental evaluation
of patients with pathology of large and small intestine
4. Assess the results of laboratory and instrumental
evaluation of patients with pathology large and small intestine
5. Diagnose the condition and formulate the diagnosis according to
current classification of patients
with pathology of large and small intestine
6. Perform differential diagnosis of
pathology of large and small intestine
7. Prescribe the appropriate
therapy for the patients with pathology of large and small intestine
Correct
answers of test evaluations and situational tasks:
Multiple
Choice. 1 – A, 2 – A, 3-A, 4-A, 5-D, 6-C, 7-D, 8-A, 9-B,10-A.
Real-life
situations. 1.
Tuberculosis 2. Campylobacter jejuni
References.
À – Basic:
2.
3.
Charles M. WienerAnthony S. Fauci
Eugene BraunwaldDennis L. KasperStephen L. HauserDan L. LongoJ.Larry JamesonJoseph LoscalzoCynthia Brown, 18th Revised edition. –
4. The Merck Manual of Diagnosis and TherapyRobert S. Porter., 19th Revised edition. -
5. Web-sites:
a) www.tdmu.edu.ua: Management of patient with chronic diarrhea syndrome Management of
patient with constipation
B – Additional:
2. Oxford Handbook of Gastroenterology
and Hepatology (2nd Revised edition). Stuart BloomGeorge WebsterDaniel Marks. –
3.
4. Mayo Clinic Gastroenterology and
Hepatology Board Review (4th Revised edition). Stephen Hauser. –
5. Web-sites:
a) http://emedicine.medscape.com/gastroenterology
Methodical
instruction has been
worked out by: assos.
prof. G.V.Lykhatska
Methodical
instruction was discussed and adopted 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 ¹17