METHODICAL INSTRUCTION FOR STUDENTS OF THE 6 COURSE

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.

 

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.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.

 

Test evaluation and situational tasks.

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

3. 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

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:

1.     Davidson's Principles and Practice of Medicine / Edited by  Nicki R. Colledge,    Brian R. Walker ,   Stuart H. Ralston, 1st Edition. - - Philadelphia : Churchill Livingstone, 2010. – 1376 p.

2. Harrison's Principles of Internal Medicine. Dan L.Longo M.D.New York : McGraw-Hill, 2012. – 4012 p.

3. Harrisons Principles of Internal Medicine Self-Assessment and Board Review /

Charles M. WienerAnthony S. Fauci

, Eugene BraunwaldDennis L. Kasper, Stephen L. HauserDan L. Longo, J.Larry Jameson, Joseph Loscalzo, Cynthia Brown, 18th Revised edition. New York : McGraw-Hill Education - Europe, 2012. – 512 p.

4. The Merck Manual of Diagnosis and Therapy / Edited by Robert S. Porter.,  19th Revised edition. -  London : Elsevier Health Sciences, 2011. – 3754 p.

5. Web-sites:

a) www.tdmu.edu.ua: Management of patient with chronic diarrhea syndrome Management of patient with constipation

 

B – Additional:

1.Textbook of Clinical Gastroenterology and Hepatology (2nd Revised edition) /

Edited by C. J. Hawkey, Jaime Bosch, Joel E. Richter, Guadalupe Garcia-Tsao, Francis K. L. Chan. – Chicester : John Wiley and Sons Ltd, 2012. – 1272 p.

2. Oxford Handbook of Gastroenterology and Hepatology (2nd Revised edition). Stuart Bloom, George WebsterDaniel Marks. – Oxford : Oxford University Press, 2012. – 648 p.

3. Harrison's Gastroenterology and Hepatology (1th edition). Dan L. LongoAnthony S. Fauci. - New York :  McGraw-Hill Education - Europe, 2010. – 752 p.

4. Mayo Clinic Gastroenterology and Hepatology Board Review (4th Revised edition).  Stephen Hauser.  Oxford : Oxford University Press Inc., 2011.  480 p

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