METHODICAL INSTRUCTION FOR STUDENTS OF THE 6 COURSE

foreign students' Faculty

module 3. current practice in internal medicine

Content module 6.Managment of patients with renal disorders

LESSON ¹ 1 (PRACTICAL – 6 HOURS)

 

Theme 21: Management of patient with urinary syndrome

 

Aim: to learn criteria for diagnosis, differential diagnosis, treatment, prognosis of the diseases with urinary syndrome .

Professional orientation of students. Although the exact incidence of CRF at its different stages is unknown, ESRD has reached epidemic levels, causing a major burden to health care resources. The incidence of new patients with ESRD in the United States in 1998 was 85,520, representing an incidence rate of 308 cases per million population; the prevalence on December 31, 1998, was 323,821 patients, representing a prevalence rate of 1160 cases per million population. An annual increase in incidence rate of approximately 7% per year since 1978 has occurred. The 5-year survival rate for a patient undergoing chronic dialysis in the United States is approximately 35%. This is approximately 20% in patients with diabetes.

 

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) (for clinical department):

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.                Urine sediment changes in glomerulonephritis.

2.                Urine sediment changes in pyelonephritis.

3.                Urine sediment changes in nephrolithiasis.

4.                Urine sediment changes in renal tuberculosis.

5.                Urine sediment changes in renal amyloidosis.

6.                Urine sediment changes in renal tumour.

7.                Involvement of the kidneys in the connective tissue diseases:

7.1.         Rheumatoid arthritis.

7.2.         Systemic lupus erythematosus.

7.3.         Systemic sclerosis.

7.4.         Sjogren's syndrome.

7.5.         Polyarteritis nodosa.

8.                Diabetic nephropathy.

9.                .Criteria of diagnostics of acute and chronic glomerulonephritis, pyelonephritis, tuberculosis, amyloidosis, renal tumour, nephrolithiasis, diabetic nephropathy, involvement of the kidneys in connective tissue diseases

10.           Differential diagnosis of acute and chronic glomerulonephritis, pyelonephritis, tuberculosis, amyloidosis, renal tumour, nephrolithiasis, diabetic nephropathy, involvement of the kidneys in connective tissue diseases

11.           Clinical diagnosis of acute and chronic glomerulonephritis, pyelonephritis, tuberculosis, amyloidosis, renal tumour, nephrolithiasis, diabetic nephropathy, involvement of the kidneys in connective tissue diseases

12.           Principles of treatment and prophylaxis of acute and chronic glomerulonephritis, pyelonephritis, tuberculosis, amyloidosis, renal tumour, nephrolithiasis, diabetic nephropathy, involvement of the kidneys in connective tissue diseases

 

Test evaluation and situational tasks.

Choose the correct answer/statement:

1.                What factors are significantly make heavier duration of acute pyelonephritis and may significantly worsen the prognosis?

A.              Proteus as the agent process

B.               Stafilococcus aureus which is coagulated plasma as a causative agent of the process

C.               Ascendant urinogenic route of infection

D.              Acute occlusion of the urinary tract

E.               Hyperuricemia

2.                What is the sign of pyelonephritis distinguishes it from other interstitial renal lesions?

A.               Tubular dysfunction in violation of the acidification of urine

B.               Resistant hypertension

C.               Edema and neutrophil infiltration of the renal pelvis

D.              The development of "the kidney, which is losing salt" with hypotension

E.               Infiltration of lymphocytes and histiocytes, and sclerosis of the renal pelvis

3.                What drugs should not be prescribed in pyelonephritis in CKD stage?

A.              Aminoglycosides

B.               Oxacillin

C.               Erythromycin

D.              Polymyxin

E.               carbenicillin

4.                Which of these diseases rarely leads to the development of pyelonephritis?

A.              Diabetes mellitus

B.               Using of hormonal contraceptives

C.               Rheumatoid arthritis

D.              Pregnancy

E.               Prostatitis

5.                Select the drug which may be effective in treating urinary tract infections.

A.              Gentamicin

B.               Nitrofuratoin

C.               Cephalexin

D.              Carbenicillin

E.               Chloramphenicol.

6.                The presence of white cell casts is diagnostic of:

A.              glomerular bleeding;

B.               glomerulonephritis:

C.               pyelonephritis;

D.              amyloidosis;

E.               deep vein thrombosis

7.                Urinary examination according to Zimnitsky is needed for evaluation of all of following except:

A.              the common diuresis;

B.               daily urine;

C.               renal clearance;

D.              night urine;

E.               fluctuation of the specific gravity of urine in every portion

8.                Urinary examination according to Nechyporenko determines:

A.                        amount of erythrocytes in 1 ml (or 1 L) of urine;

B.                        amount of leucocytes in 1 ml (or 1 L) of urine;

C.                        amount of casts in 1 ml (or 1 L) of urine

D.                        all of them;

E.                         none of the above

 

Real-life situations to be solved:

1 A 44-year-old man is referred to you for evaluation and treatment of recurrent renal colic and passage of renal stones. What kind of examination will you choose?

2. A 30-year-old woman complains of dysuria, fever, shaking chills, nausea, vomiting, and diarrhea, generalized muscle tenderness. Physical examination reveals tachycardia, marked tenderness on deep pressure in both costovertebral angles and on deep abdominal palpation. What kind of examination will show changes and what changes will you expect to see?

 

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)

 

Student should know:

1. Modern views of the etiology, pathogenesis of acute and chronic glomerulonephritis, pyelonephritis, tuberculosis, amyloidosis, renal tumour, nephrolithiasis, diabetic nephropathy, involvement of the kidneys in connective tissue diseases

2. Classification of acute and chronic glomerulonephritis, pyelonephritis, tuberculosis, amyloidosis, renal tumour, nephrolithiasis, diabetic nephropathy, involvement of the kidneys in connective tissue diseases

3. Clinical, laboratorial findings of acute and chronic acute and chronic glomerulonephritis, pyelonephritis, tuberculosis, amyloidosis, renal tumour, nephrolithiasis, diabetic nephropathy, involvement of the kidneys in connective tissue diseases Differential diagnosis of acute and chronic pyelonephritis

4. Differential diagnosis of acute and chronic glomerulonephritis, pyelonephritis, tuberculosis, amyloidosis, renal tumour, nephrolithiasis, diabetic nephropathy, involvement of the kidneys in connective tissue diseases

5. Treatment acute and chronic glomerulonephritis, pyelonephritis, tuberculosis, amyloidosis, renal tumour, nephrolithiasis, diabetic nephropathy, involvement of the kidneys in connective tissue diseases 

 

Student should be able to:

1. History taking and physical examination of the patients with acute and chronic glomerulonephritis, pyelonephritis, tuberculosis, amyloidosis, renal tumour, nephrolithiasis, diabetic nephropathy, involvement of the kidneys in connective tissue diseases

2. To determine main clinical syndromes in patients with acute and chronic glomerulonephritis, pyelonephritis, tuberculosis, amyloidosis, renal tumour, nephrolithiasis, diabetic nephropathy, involvement of the kidneys in connective tissue diseases

3. To compose the plan of laboratory and instrumental examination of the patient with acute and chronic glomerulonephritis, pyelonephritis, tuberculosis, amyloidosis, renal tumour, nephrolithiasis, diabetic nephropathy, involvement of the kidneys in connective tissue diseases s.

4. To interpret the results of laboratory and instrumental methods of examinations.

5. To put clinical diagnosis according to clinical classifications.

6. To make differential diagnosis of urinary syndrome

7. Prescribe the treatment of acute and chronic glomerulonephritis, pyelonephritis, tuberculosis, amyloidosis, renal tumour, nephrolithiasis, diabetic nephropathy, involvement of the kidneys in connective tissue diseases

8. Evaluate prognosis for patient with acute and chronic glomerulonephritis, pyelonephritis, tuberculosis, amyloidosis, renal tumour, nephrolithiasis, diabetic nephropathy, involvement of the kidneys in connective tissue diseases

 

 

Correct answers of test evaluations and situational tasks:

Multiple Choice. 1. A,B,D; 2. C,E; 3. A,E; 4. B,C; 5 – C; 6 – Ñ; 7 – C; 8 D;

Real-life situations. 1. Intravenous pyelography. 2. The routing urine analysis. Microscopic examination of urine reveals numerous pus cells and organisms, some red cells and epithelial cells. Pyuria and low level proteinuria are common for chronic pyelonephritis, but not invariable.

 

References.

A - Basic:

1.                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)                  www.tdmu.edu.ua: Management of  patients with urinary syndrome

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

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

 

B – Additional:

1.                                                         Lawrence M. Tierney, Jr. et al: Current Medical Diagnosis and treatment 2000, Lange Medical Books, McGraw-Hill, Health Professions Division, 2000.

 

 

Methodical instruction has been worked out by: assist. prof. Gusak S.R.

Methodical instruction was discussed and adopted 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