METHODICAL INSTRUCTION
for Practical Class for 5-years students of Foreign Students’ Faculty
LESSON № 2 (PRACTICAL – 6 HOURS)
Theme: Management of pediatric medical records of general practitioner family medicine. Clinical supervision of children with disorders of the digestive system and blood circulation in the family doctor’s practice.
Aim:
– Identify the different clinical variants and the complications of cardiovascular diseases in children, accompanied by cardiomegaly.
– Identify tactics for the patient with the most common cardiovascular diseases in children, accompanied by cardiomegaly (myocarditis, endocarditis, pericarditis, cardiomyopathy, congenital and acquired heart defects)
– Demonstrate the ability of medical records of sick children with pathology of the cardiovascular system, to plan investigation of the sick child and interpret the results at myocarditis, endocarditis, pericarditis, cardiomyopathy, congenital and acquired heart defects in children.
-To make differential diagnosis of inflammatory and noninflammatory cardiovascular diseases in children, accompanied by cardiomegaly and put a clinical diagnosis, provide emergency aid at acute heart failure.
Prescribe treatment and prevention of chronic heart failure.
Professional orientation of students:
In recent years the proportion of congenital heart disease (CHD) and non-rheumatic myocarditis in the structure of the cardiovascular disease has increased. Among children with CHD mortality was approximately 23%, with about 90% of children who die within the first year of life. Timely diagnosis, adequate aid at the development of complications, surgical treatment at the optimum time determine the prognosis for life and social adaptation of children with congenital heart disease.
Non-rheumatic carditis may occur in healthy children and have rapidly progressive course with the development of heart failure and arrhythmias, approximately in one-third of children as a result of myocarditis dilated cardiomyopathy develops. Despite the decline in the incidence of acute rheumatic fever, the relevance of this issue remains high in relation to circulation, the remaining group A streptococcus in the population, as well as the prevalence of latent protracted course of rheumatism with a high probability in this formation in patients with acquired heart defects. Thus, knowledges of clinical signs of inflammation in the myocardium, the ability to make differential diagnosis with non-inflammatory heart diseases, knowledge of the therapy principle and urgent care are needing in the practice of doctor of any speciality.
Acute cardiovascular insufficiency in children may occur not only at diseases of the cardiovascular system, as well as serious infectious diseases. Doctor ofany specialty should be able to provide immediate care and be able to diagnose non-rheumatic carditis and congenital heart defects in children to nominate an individual treatment, preventive measures. This explanation defines the actuality of the topic.
Methodology of Practical Class (900-1200 hour).
Cardiovascular diseases in children, accompanied by cardiomegaly.
Work 1 Collect the medical history, conduct an objective examination of the patient according algorithm communication skills.
1.Friendly facial expression and smile.
2.Gentle tone of speech.
3.Greeting and introducing.
4. Explain to the parents what examination should be performed and obtain their informed consent.
5. Prepare for examination (clean and warm hands, warm phonendoscope, etc.).
6. Examination.
7. Explaining the results of examination to baby’s parents.
Determine the possible etiological factors and risk factors. Identify the complaints, which can describe congenital heart disease or carditis.
Work 2. Identify main clinical symptoms and syndromes of the diseases of the cardiovascular system in children, accompanied by cardiomegaly. Know the clinical variants of the course and complications of myocarditis, endocarditis, pericarditis, cardiomyopathy, congenital and acquired heart defects in children.
Differential diagnosis of cardiomegaly in children.
Work 3. During examination the patient to use communication skills – a friendly face, a smile, preparation for the observation (clean warm hands, warm phonendoscope).
Treatment. Explanation of the treatment to the child’s parents. Diagnosis during the inspection of patients with non-rheumatic carditis or congenital heart disease. Estimate the form of carditis, severity, stage and form of heart failure. Interpret the data of additional methods of examination.
Work 4. Interpret the data of laboratory and instrumental studies at myocarditis, endocarditis, pericarditis, cardiomyopathy, congenital and acquired heart defects in children. Conduct a differential diagnosis of inflammatory and noninflammatory diseases of the cardiovascular system in children, accompanied by cardiomegaly. Tactics to a patient with myocarditis, endocarditis, pericarditis, cardiomyopathy, congenital and acquired heart defects in children.
First Aid at acute heart failure.
Work 5. Correct and easy to understand the child’s parents an explanation of the expected results, which are appointed to the child. Involving parents in the conversation (emphasis on the importance of continuous treatment, compliance with assigned treatment regimen, to determine clearly whether they understandyour explanation. Prescribe treatment: etiologic, pathogenetic, symptomatic, the correct diet and treatment.
Work 6. Providing emergency aid at acute heart failure, with dyspnea-cyanotic attack, pulmonary edema, acute heart failure, therapeutic methods atdecompensation. Treatment and prevention of chronic heart failure.
Program of students self activity.
1. Etiology and pathogenesis of non-rheumatic carditis in children, diagnosis of non-rheumatic carditis.
2. Methods of treatment of non-rheumatic carditis.
3. Preventive and rehabilitation measures:
a) prevention of carditis;
b) clinical examination of patients;
a) rehabilitation.
4. Congenital heart defects: etiology and classification of congenital heart heart defects.
5. Paraclinical methods of investigation at congenital heart defects.
6. Complications of congenital heart disease.
7. Principles of treatment depending on the cardiovascular failure:
a) treatment in the phase of decompensation;
b) surgical correction of defects.
8. Causes of acute cardiovascular failure.
9. The main clinical signs of cardiovascular failure.
10. Classification of acute cardiac and circulatory failure.
11. The volume of laboratory and instrumental examination in acute cardiac and circulatory insufficiency according to the principles of evidence-based medicine: – ECG, echocardiography, PCG, pO2, pCO2 in the blood – the level of evidence A, general blood test, Ro-graphy of the chest, blood chemical analysis (protein, urea , creatinine, ALT, AST) – the level of evidence B, general urinalysis, EEG – the level of evidence C.
12. Urgent therapy at acute heart and circulatory insufficiency according to the principles of evidence-based medicine: – cardiac glycosides, β-blockers, diuretics, defoamers – the level of evidence A, antiarrhythmic, vasodilators, angioprotectors – the level of evidence B, vitamins, microelements, hormones – the level of evidence C.
13. Pathogenetic mechanisms and factors contributing to violations
rhythm in children. Classification of rhythm disorders in children.
14. Diagnostics of arrhythmia due to dysfunction of sinus node automaticity.
15.Diagnostika of ectopic complexes and rhythms: migration pacemaker,
extrasystoles.
16. Diagnostics and clinical manifestations of dysfunctions of conductivity.
17. Diagnostics of paroxysmal tachycardia and atrial fibrillation.
18.Treatment and prevention of arrhythmias.
Seminar discussion of theoretical issues (1230 – 1400 hour).
1. Leading clinical symptoms and syndromes are diseases of the cardiovascular system in children, accompanied by cardiomegaly.
2. Clinical variants of the course and complications of myocarditis, endocarditis, pericarditis, cardiomyopathies, congenital and acquired heart defects in children.
3. Laboratory and instrumental investigations at myocarditis, endocarditis, pericarditis, cardiomyopathy, congenital and acquired heart defects in children.
4. Differential diagnosis of patients with inflammatory and noninflammatory diseases of cardiovascular system in children, accompanied by cardiomegaly.
5. Tactics to a patient with myocarditis, endocarditis, pericarditis, cardiomyopathy, congenital and acquired heart defects in children.
6. Providing emergency care at acute heart failure.
7. Treatment and prevention of chronic heart failure.
8. Leading clinical symptoms and syndromes of the cardiac arhythmia in children.
9. Clinical variants of the course and complications of cardiac arhythmia in children.
10. Data of instrumental investigations at cardiac arhythmia in children.
11. Differential diagnosis at cardiac arhythmia in children.
12. Tactics to the patient with cardiac arhythmia in children.
13. Provision of emergency assistance at the cardiac arhythmia in children.
14. Treatment and prevention of cardiac arrhythmia in children.
Test evaluation and situational tasks.
Multiple Choice Questions
Choose the correct answer/statement
Tests:
1. Specify the correct statement about syncope.
A. Sudden, usually brief loss of consciousness caused by severe anemia of the brain *
B. Arises as a result of psychogenic effects on the regulation of blood
C. Arises as a result of a reflex influence on the regulation of blood
D. Mild form of vascular insufficiency
E. All listed
2. Specify the cause of acute right ventricular failure.
A. Asthmatic status *
B. Acute myocarditis
C. Congenital carditis
D. Cardiomyopathy
E. Rheumatic
3. Clinical sign of syncope is:
A. Vomiting
B. The sudden loss of consciousness *
C. Gradual loss of consciousness
D. Weakness
E. Dizziness
4. The best medications for vagotonic collapse are:
A. Droperidol, chlorpromazine
B. Euphyllin, salbutamol
C. Kordiamin, caffeine
D. Reopolyglucin, polyglucin
E. Adrenaline, mezatone *
5. Specify indications for prescription of cardiac glycosides.
A. Cardiac insufficiency*
B. Atrioventricular blockade
C. Expressed bradycardia
D. Group extrasystoles
E. Expressed hypokaliemia
Situational problems.
1. Febrile fever, dyspnea, arthralgia appeared in a child 7 years old in 2 weeks after a sore throat. On examination: skin is pale, expressed pulsation on the apex. Tonsils are hypertrophic, sclerotic changed, submandibular lymph nodes are enlarged up to 1 cm in diameter. Percussion: left heart border of the relative cardiac dullness to 2 cm outside the left middle clavicular line. Cardiac tones are considerably weak, systolic blowing murmur on the apex and the V pointwith conduction on the left armpit. Heart rate is120 per minute. Acute rheumatic fever is suspected. What may clarify the degree of inflammatory process?
A. Fibrinogen serum
B. ASLO titer
C. Acute phase indicators
D. ECG
E. Echocardiography
2. The child is registered on the chronic rheumatic heart disease, insufficiency of mitral valve. Select a medicine to prevent a recurrence of the disease in a patient.
A. Amoxicillin
B. Makropen
C. Bicillin -5
D. Cefotaxime
E. Ortofen
3. Shortness of breath, tachycardia, anxiety suddenly appeared in the child 3 weeks old. Auscultation of the lungs: breathing puerile, wheezing are absent. Cardiac tones are weak, tachicardia. Systolic murmur is auscultated in the left subclavian area and under the left angle of scapular. It was suspectedcongenital heart defect – coarctation of the aorta. Which of the investigations may help to put the diagnosis?
A. Measurement of blood pressure in the upper and lower extremities
B. Hyperoxidal test
C. Palpation of atrial area
D. Percussion cardiac dullness boundaries
E. Inspection of the nails
4. In a child of 3 years 2 weeks after the ARVI shortness of breath, cough, fever have appeared. Percussion: clear lung sounds, auscultatation; breath puerile,in lowback areas on both sides fine moist rales. Quiet heart sounds, gallop rhythm, systolic murmur over the entire atrial region. The liver is enlarged to 3cm from the edge of the costal arch. Non-rheumatic carditis is suspected.
X-rays of the chest was done. Which of the following changes indicate on diagnosis?
A. Increased of cardio-thoracic index
B. Increased of thimic-thoracic index
C. Changes in pulmonary image
D. Reduced cardio-thoracic index
E. Enlargement of pulmonary artery
5. Doctor finds the heart murmur in the child 2 months old. Mother is 28 years old. It is III pregnancy, accompanied by chronic pyelonephritis, the presence of markers of CMV infection. She was ill ARVI in term 2 and 8 months of pregnancy. Two previous pregnancies were interrupted by spontaneous abortions.Father was operated in childhood at the CHD. What is the cause of the CHD in the child?
A. CHD in the father
B. Chronic pyelonephritis in the mother
C. Presence of markers of CMV infection
D. ARVI at 2 months of pregnancy
E. All of listed
Answers on situational problems:
1 C, 2 C, 3 A, 4 A, 5 E
Individual student work (1415-1500 hour) 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. The anatomic and physiological features of the cardiovascular system in children.
2. Accordance of physical development to the child age.
3. An objective examination of the patient.
4. Investigation of the cardiovascular system.
5. Analyzing of the data of the objective and additional methods of examination according to the morphofunctional peculiarities in children.
6. Interpretation of the changes in hemodynamics.
7. Etiology and pathogenesis of non-rheumatic carditis in children.
8. Classification of non-rheumatic carditis.
9. Diagnostic of non-rheumatic carditis.
10. Methods of treating non-rheumatic carditis.
11. Prevention and rehabilitation of non-rheumatic carditis.
12. Mechanisms of action of cardiac glycosides, diuretics, heart drugs.
Students should be able to:
1. Identify the etiological factors of carditis.
2. To diagnose non-rheumatic carditis.
3. Make a differential diagnosis of such diseases.
4. Put the diagnosis according to classification.
5. Prescribe treatment, preventive and rehabilitative measures.
6. Identify in anamnesis the possible etiological factors of congenital heart defects.
7. Recognize the clinical signs of congenital heart defects.
8. Analyze data of laboratory and instrumental methods of investigation.
9. Put clinical diagnosis based on clinical and laboratory-instrumental data.
10. Prescribe the complex treatment.
11. Plan prevention, rehabilitation measures and dispensary observations, enter on sanatorium treatment.
12. Draw the pedigree to establish the mechanism of transmission of hereditary disease.
Referens:
1. Pediatrics. Textbook. / O. V. Tiazhka, T. V. Pochinok, A. N. Antoshkina et al. / edited by O. Tiazhka – Vinnytsia : Nova Knyha Publishers, 2011 – 584 pp. : il.
2. ISBN 978-966-382-355-3Nelson Textbook of Pediatrics, 19th Edition Kliegman, Behrman. Published by Jenson & Stanton, 2011, 2608. ISBN: 978-080-892-420-3.
3. Illustrated Textbook of Paediatrics, 4th Edition. Published by Lissauer & Clayden, 2012, 552 p. ISBN: 978-072-343-566-2.
4. Denial Bernstein. Pediatrics for medical Students. – Second edition, 2012. – 650 p.
Web -sites:
1.http://intranet.tdmu.edu.ua/data/kafedra/internal/index.php?&path=policlin/classes_stud/
2. http://www.merckmanuals.com/professional/index.html
3. http://www.nemours.org/content/dam/nemours/www/filebox/service/medical/cardiology/defect/tof.swf
6. http://www.nemours.org/content/dam/nemours/www/filebox/service/medical/cardiology/defect/vsd.swf
8. http://www.nemours.org/content/dam/nemours/www/filebox/service/medical/cardiology/defect/pda.swf
The methodical instruction has been worked out by: N. Botcyk
The methodical instruction was discussed and adopted at the Department sitting
27/08/2013 Minute № 1
The methodical instruction was adopted and reviewed at the Department sitting
__________201 . Minute № ___
