METHODICAL INSTRUCTION FOR STUDENTS OF THE 6 COURSE

foreign students’ Faculty

MODULE 2. PRINCIPLES OF INTERNAL MEDICINE

(cardiology, rheumatology, nephrology, common questions of internal medicine)

Content module 1. Principles of diagnosis, management and prevention of main cardiovascular diseases

 

LESSON № 8 (PRACTICAL – 6 HOURS)

 

Theme 8: Cardiomyopathies

Aim: to develop skills and to acquire experience relevant to management of patients with cardiomyopathies.

Professional Motivation: Hypertrophic cardiomyopathy (HCMP) is the most common inherited cardiovascular disorder, affecting up to 1 in 500 of the general population. It is the leading cause of sudden death in athletes aged <35. Restriclive cardiomyopathy and arrhythmogenic right ventricular dysplasia are the least commonly encountered forms of cardiomyopathy.

 

 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. Etiology and pathophysiology issues.

2. Classification

3. Main clinical findings

4. Main laboratory and instrumental findings

5. Management strategies: principles of choice of the right strategy

6. Drug therapy: indications and contraindications

Test evaluation and situational tasks.

Multiple Choice Questions

Choose the correct answer/statement

1.    Which of the following is NOT characteristic of HCMP?

A.  Hypercontractility of the LV free wall

B.   Hypocontractility of the IVS

C.   Predominant systolic dysfunction

D.  Predominant diastolic dysfunction

2.    Primary causes of diastolic heart failure include all of the following EXCEPT

A.  Hypertrophic cardiomyopathy

B.   Dilated cardiomyopathy

C.   Hypertension

D.  Coronary artery disease

E.   Infiltrative cardiomyopathy

3.           43 year-old female had a history: old female had a history of shortness of breath and palpitations for 7 years with a progressive increase one month before death. She was known to have both systolic and diastolic murmus, dilated chambers. Choose the most likely diagnosis from the below list of options.

A.         *Dilated cardiomyopathy

B.         Infective endocarditis

C.         Degenerative valvular disease

D.         Connective tissue disease

E.          Congenital valvular disease

4.           Which of the following EchoCG changes is found in restrictive cardiomyopathy?

A.         Left ventricular dilatation

B.         Left ventricular diastolic dysfunction

C.         *Increased left ventricular wall thickness

D.         Asymmetric septal hypertrophy

E.          Systolic anterior motion (SAM) of the mitral valve

5.    All are true about Hypertrophic Obstructive cardiomyopathy, except:

A.  β agonist are useful

B.   Asymmetrical hypertrophy of septum

C.   Dynamic L.V. outflow obstruction

D.  Condition improves on passive leg raising

E.   Systolic murmur

6.           Which of the following EchoCG changes is found in dilated cardiomyopathy?

A.         *Left ventricular dilatation

B.         Left ventricular diastolic dysfunction

C.         Increased left ventricular wall thickness

D.         Asymmetric septal hypertrophy

E.          Systolic anterior motion (SAM) of the mitral valve

7.            What is the main cause of death in patient with dilated cardiomyopathy?

A.         Pulmonary embolism

B.         Stroke

C.         Myocardial infarction

D.         Pulmonary edema

E.          *Fatal arrhythmias

8.           Standard therapy of heart failure in dilated myocardiopathy includes all of the following EXCEPT:

A.         Salt restriction

B.         Angiotensin-converting enzyme (ACE) inhibitors

C.         *Calcium channel blockers

D.         Diuretics

E.          Digitalis

9.    Dilated cardiomyopathy often producing symptom of:

A.  congestive heart failure

B.   bradycardia

C.   angina pectoris

D.  paradoxic pulse

E.   elevated serum levels of myocardial enzyme.

10. Interventions that may all cause an increase in the gradient and the murmur in patients with hypertrophic cardiomyopathy are following except:

A.  digitalis glycosides

B.   diltiazem

C.   sudden standing

D.  Exercise

E.   tachycardia

 

Real-life situations to be solved:

1. A 31-year-old woman with HCMP presents to your office for follow-up. She has been doing well. She denies any palpitation or syncope. She has researched on her disease on the Web and found out that most people die of arrythmia. She would like to have an electrophysiological (EP) study. What is your answer?

2. A 49-year-old man is admitted with new-onset heart failure. He is diagnosed with dilated cardiomyopathy with an EF of  20%. On hospital day 1, he is diuresed and started on a regimen of furosemide, digoxin, aspirin, captopril, and simvastatin. A medical student wants to know why you did not start him on a beta-blocker. What is your explanation?

3. The same medical student also wants to know whether the patient should also be started on calcium channel blockers. What is your answer?

 

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 cardiovascular anatomy and physiology.

2. Anatomy and hemodynamics in patients with cardiomyopathies.

2. Relevant terminology, definitions and classifications of cardiomyopathies.

3. Chief complaints of patients with cardiomyopathies.

4. Evaluation of basic signs and symptoms in patients with cardiomyopathies.

5. Specific signs and symptoms of cardiomyopathies.

6. Methods of physical examination of cardiovascular patients.

7. Methods of laboratory evaluation of cardiovascular patients.

8. Methods of instrumental evaluation of cardiovascular patients.

9. Principles of management.

 

Students should be able to:

1. Perform a clinical exam of cardiovascular patients.

2. Reveal main clinical syndromes.

3. Draft a plan of laboratory and instrumental evaluation of cardiovascular patients.

4. Assess the results of laboratory and instrumental evaluation.

5. Diagnose the condition and formulate the diagnosis according to current classification.

6. Perform differential diagnosis.

7. Prescribe the appropriate therapy.

 

Correct answers of test evaluations and situational tasks:

Multiple Choice Questions. 1 – C. 2 – B. 3-A. 4-C. 5-A. 6-A.7-E. 8-C. 9-A. 10-B.

Real-life situations. 1. there is no role for routine EP study in the asymptomatic HCMP patient 2. beta-blockers should be started in stable CHF patiens; they should not be started when the patient is congested. 3. amlodipine proved to be of small benefit in a NYHA class III or IV patients with an EF<30%. This benefit was seen more in dilated (nonischemic) cardiomyopathy patients.

 

References:

A – Basic:

1.                 Davidson’s Principles and Practice of Medicine (1st Edition) / Edited by  N. R. Colledge,    B. R. Walker,   S. H. Ralston. – Philadelphia : Churchill Livingstone, 2010. – 1376 p.

2.                 Harrison’s Principles of Internal Medicine / Dan L. Longo, A. S. Fauci, D.L. Kasper [et al.]. – New York : McGraw-Hill, 2011. – 4012 p.

3.                 Kumar and Clark’s Clinical Medicine (8th Revised edition) (With STUDENTCONSULT Online Access) / Edited by P. Kumar, M. L. Clark,  . – London : Elsevier Health Sciences, 2012. – 1304 p.

4. Web -sites: www.tdmu.edu.ua: Cardiomyopathies

 

 B – Additional:

1. Braunwald’s Heart Disease Review and Assessment  / L. S. Lilly. – Philadelphia : Elsevier – Health Sciences Division, 2012. – 320 p.

2. Cleveland Clinic Cardiology Board Review / by Cho L., Griffin B.P., Topol E.J., eds. – Lippincott Williams & Wilkins, 2009. – 385 p.

3. Oxford Handbook of Cardiology (2nd Revised edition) / Edited by P. Ramrakha, J.Hill. – Oxford : Oxford University Press, 2012. – 880 p.

4. Clinical Echocardiography (2 revised edition) / Edited by M. Y. Henein. – England : Springer London Ltd., 2012. – 328 p.

5. Mayo Clinic Cardiology: Concise Textbook  (4^rd ed.) / by Murphy J.G., Lloyd M.A., eds. – New York : Oxford University Press Inc., 2012. – 1608p.

6. 2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy // Circulation. 2011; 124: e783-e831

7. Web -sites:

http://emedicine.medscape.com/cardiology

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

 

 

 

Methodical instruction has been worked out by:  assos. prof. R.R. Komorovsky, MD

Methodical instruction was discussed and adopted at the Department sitting 09.01.2013 Minute №10

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