METHODICAL INSTRUCTION FOR STUDENTS OF THE 6 COURSE

FOREIGN STUDENTS' FACULTY

Module 3. Current practice in internal medicine

Content module 4. “Management of the patients with disorders of respiratory system”

LESSON № 3 (PRACTICAL – 6 HOURS)

Theme 16: Management of patients with pleural effusion

Aim: to learn and practice the skills of clinical diagnostics of the most informative sings of pleural effusion, to study laboratory and instrumental diagnostic, differential diagnostic and how to make the individual plan of treatment according to the reason of pleural effusion.

Professional orientation of students. The estimated incidence is 1 million cases per year, with most effusions caused by congestive heart failure, malignancy, infections, and pulmonary emboli. The estimated prevalence is 320 cases per 100,000 people in industrialized countries, with a distribution of etiologies related to the prevalence of underlying diseases.

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 14.15-15.00 (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.     What is pleuritis?

2.     Etiology and pathogenesis of pleuritis.

3.     Classification of pleuritis.

4.     Main symptoms and syndromes characteristic for pleuritis.

5.     Clinical findings in patients with pleuritis.

6.     Laboratory and instrumental methods of investigation of pleuritis.

7.     Differential diagnostic of pleuritis and tuberculosis of lungs.

8.     Peculiarities of treatment of patients with pleuritis.

Test evaluation and situational tasks.

Choose the correct answer/statement:

1.     What is one of the causes of pleuritis?

A. appendicitis

B. ectopy of aorta

C. myocardial infarction

D. atherosclerosis

E. heart insufficiency

2.     The most typical symptoms of pleuritis are:

A. Pleuritic pain, shallow breathing, coughing

B. Pleuritic pain, dizziness, tachicardia

C. High temperature, vomiting, obstipation

D. Law temperature, sweating

E. Pleuritic pain, vomiting, sneezing

3.     What drugs are used in treatment of pleuritis?

A. Sedatives

B. Antibiotics

C. b-blockers

D. antidepressants

E. vitamins

4. One of the following condition is not associated with clubbing.

A. Primary biliary cirrhosis

B. Chronic bronchitis

C. Cryptogenic fibrosing alveolitis

D. Central bronchiectasis

E. Nothing of the above

5. A drug is to be delivered by a nebuliser. The size of a droplet for its humidification is:

A. <5

B. 5-10

C. 10-15

D. 15-20

E. All of the above

6. α1- Antitrypsin deficiency is associated with:

A. Centriaciner emphysema

B. Panaciner-emphysema

C. Irregular emphysema

D. Paraseptal-emphysema

E. All of the above

7. Volume of air taken into the lungs in normal respiration is known as:

A. Vital capacity

B. Timed vital capacity

C. Tidal volume

D. Inspiratory reserve volume

E. All of the above

8. Decreased maximum mid-expiratory flow rate indicates obstruction in:

A. Small airways

B. Trachea

C. Large airways

D. Trachea & bronchi both

E. Nothing of the above

9. Features of restrictive lung disease is:

A. FEV₁/FVC decreases and compliance decreases

B. FEV₁/FVC increases and compliance increases

C. FEV₁/FVC decreases and compliance increases

D. FEV₁/FVC increases and compliance decreases

E. Nothing of the above

10. All are decreased in infiltrative lung disease, except:

A. Vital capacity

B. Alveolar arterial difference in PaO₂

C. Total lung capacity

D. Lung compliance

E. Nothing of the above

Real-life situations to be solved:

1. Patient complaints on severe cough with production of 600 ml a day purulent sputum of chocolate color with a putrid smell. Felt ill suddenly, temperature - 39 °С. On the X-ray film there is an area of darkening with cavities in a center, with unclear contours and with the level of fluid. What disease may be suspected?

A. Bronchiectasis

B. Pulmonary gangrene

C. Tuberculosis cavern

D. Pulmonary abscess

E. Cancer of lungs with destruction

2. A 37-yr-old man who has had recurrent chest infections since a serious bout of influenza 3-yr ago presents with chronic productive cough. His sputum is tenacious and blood stained. On auscultation you find crackling. What changes may be founded on X-ray?

A. Round shadow with horizontal level of fluid

B. Infiltration

C. Round shadow

D. Signs of fibrosis and hyperpneumatization

E. Signs of fibrosis and local infiltration

3. Man, 54 y.o., complaints on pain in a thorax, dyspnea, cough with sputum with blood. In anamnesis: long history of cough with purulent sputum to 200 ml per day, mostly in the morning, periodically increasing of temperature to 37,8 °С, sweating, chills. Smokes since 14. Objectively: low weight, skin with grey tint, oedema of face, fingers are like "drumsticks", in lings there is pulmonary and band-box sound, dull sound, dry and moist rales. In blood: leucocytosis, moderately increased ESR. What is the most possible cause of pulmonary bleeding in this case?

A. Chronic bronchitis

B. Tuberculosis

C. Pulmonary cancer

D. Pulmonary abscess

E. Bronchiectasis

4. Patient W., 62 y.o., suffers with morning caugh with expectoration of large volume of greenish sputum. The sputum is better expelled in a certain position of patient’s body. Occuring of a such kind of caugh is typical for

A. pneumonia

B. asthma

C. emphysema

D. bronchiectatic disease

E. pleurisy

5. Patient of 51, complaints on expressed dyspnea, pain in the left part of thorax. Objectively: breathing rate - 30/min., heart rate - 108/min. Above the left part of thorax vocal fremitus is significantly decreased, during percussion sound is dull, auscultation – weak vesicular breathing. X-ray – homogeneous shade to the level of 2nd rib with diagonal upper border, organs of mediastinum are displaced to the right. Method of choice in the treatment of this patient is:

A. Pleural punction

B. Intravenous usage of large doses of glucocorticosteroids

C. Emergency bronchoscopy

D. Inhalation of b2-agonists of short action

E. Intravenous usage of antibiotics

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.     What is pleuritis?

2.     Etiology and pathogenesis of pleuritis.

3.     Laboratory and instrumental methods of investigation of pleuritis.

4.     Interpretation of received results of sputum, spyrography, spyrometry and peakflowmetry, roentgenography and tomography of chest organs.

5.     Clinical characteristic and differential diagnostic of the lung diseases with pleuritis.

6.     Peculiarities of treatment of patients with pleuritis.

7.     Prophylaxis of the lung diseases with pleuritis.

Students should be able to:

1. To examine the patient with disorders of respiratory system (collection of complaints and anamnesis, objective examination of the patients).

2. To make a plan of laboratory and instrumental methods of investigation of the patients with disorders of respiratory system.

3. Estimate results of laboratory and instrumental methods of investigation.

4. To diagnose the diseases of respiratory system with pleuritis.

5. To make differential diagnostics of the lung diseases with pleuritis.

6. Prescribe treatment for patients with diseases of respiratory system with pleuritis.

Correct answers of test evaluations and situational tasks:

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

Real-life situations 1 – D, 2 – A, 3 – E, 4 – D, 5 – A.

References:

A - Basic:

1. Davidson’s Principles and practice of medicine (21^st 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 (18^th 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) www.tdmu.edu.ua: Management of the patients with pleural effusion

b) http://emedicine.medscape.com/

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

B – Additional:

1. Respiratory diseases / Ghanei M. – In Tech, 2012. – 242 p.

2. Clinical respiratory medicine / Spiro S., Silvestri G., Agustí A. – Saunders, 2012. – 1000 p.

3. Principles and practice of interventional pulmonology / Ernst A., Herth F. –Springer, 2012. – 757 p.

4. Chest x-rays for medical students / Clarke C., Dux A. – Wiley-Blackwell, 2011. – 134 p.

Methodical instruction has been worked out by assoc. prof. Lepyavko A.A.

Methodical instruction was discussed and adopted at the Department sitting “12” June, 2012. Minute № 12

Methodical instruction was adopted and reviewed at the Department sitting “25” June, 2013. Minute № 17