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 № 2 (PRACTICAL – 6 HOURS)

Theme 2: Secondary hypertension

 

Aim: to develop skills and to acquire experience relevant to management of patients with secondary hypertension: renal hypertension (vascular, parenchymal), endocrine (pheochromocytoma, Cushing’s syndrome, primary aldosteronism, acromegaly, Liddle syndrome), coarctation of the aorta, pre–eclampsia, acute intermittent porphyria.

Professional Motivation: For hypertensive patients who are resistant to treatment with two or more agents, a number of clinical clues can suggest the possible presence of secondary hypertension. Secondary hypertensive disorders can be effectively treated or cured, leading to partial or complete normalization of resistant hypertension in most patients. The availability of medication and increased public awareness of hypertension have decreased  the total number of hypertensive emergencies, the importance of appropriate medication selection and achieving blood pressure-lowering rates in critical to the success of avoiding end-organ damage in this setting.

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. A patient with aortic coarctation is most likely to have which of the following cardiac abnormalities?

A.          Bicuspid aortic valve*

B.          Mitral stenosis

C.          Preexitation syndrome

D.          Right bundle branch block

E.           Tricuspid atresia

2. A 48-year-old obese male with hypertension, dyslipidemia, and diabetes mellitus presents to the outpatient clinic for his yearly physical. He has refused medications in the past, but now is willing to consider treatment. His BP is 145/95 mmHg with a HR of 80 bpm. His laboratory data are significant for the presence of microalbuminuria. Which of the following medications would be the most appropriate?

A.               Carvedilol

B.               Methyldopa

C.               Lisinopril*

D.               Chlorthalidone

E.                Terazozin

3. A 42-year-old male comes in for a routine physical examination. He is noted to have a BMI of 30, impaired fasting glucose, and a BP of 135/85 mmHg. What is the best treatment plan for this individual?

A.               Aggressive lifestyle modification*

B.               Institute thiazide diuretic regimen

C.               No treatment at this time

D.               Initiate an ACE-inhibitor

E.                Initiate a beta-blocker

4. A 62-year-old man with isolated essential hypertension, currently taking hydrochlorothiazide 25 mg PO daily, comes to you for his first clinic visit. He notes that his BP at home is always less than 140/80 mmHg, but in clinic it is always at least 155/95 mmHg. What is the next step?

A.               Increase dose of thiazide

B.               Addition of second antihypertensive medication

C.               Do nothing as he has white coat hypertension*

D.               Evaluate for secondary causes of hypertension

E.                Start metoprolol

5. A 34-year-old male with isolated essential hypertension presents to clinic and is found to have a BP of 180/100 mmHg after failure of behavioral modifications. What is the most appropriate next step?

A.               Start hydrochlorothiazide

B.               Start hydrochlorothiazide and lisinopril*

C.               Repeat BP in 4 weeks

D.               Start amlodipine

E.                Start doxazozin

6. A 56-year-old male on hydralazine, hydrochlorothiazide, lisinopril, and metoprolol begins to develop a malar rash and arthralgias. Which of the above antihypertensive agents is known to cause drug-induced lupus?

A.               Hydrochlorothiazide

B.               Lisinopril

C.               Hydralazine*

D.               Metoprolol

E.                None of the above

7. Thiazide diuretics can contribute to each of the following metabolic effects EXCEPT:

A.               Hypomagnesemia

B.               Hypouricemia*

C.               Hypercalcemia

D.               Hypercholesterolemia

E.                Hyponatremia

8. Which of the following statements regarding prevention of stroke is correct?

A.               Treatment of systolic hypertension does not decrease the risk of stroke in patients older than age 60

B.               Hypertension should not be a target of secondary prevention after an ischemic stroke because elevated BP is desirable to maintain adequate cerebral perfusion

C.               Treatment with HMG-CoA reductase inhibitors reduces the risk of recurrent stroke*

D.               The combination of aspirin and clopidogrel is superior to aspirin alone for prevention of recurrent stroke

E.                None of the above

9. You see a diabetic patient presents with BP readings that are 155/95 or higher. All of the following statements about the treatment of this patient’s hypertension are correct EXCEPT:

A.               Pharmacologic blocade of the renin-angiotensin system reduces the risk of both microvascular and macrovascular events

B.               Aggressive BP control reduces cardiovascular events more in diabetics than iondiabetics

C.               Calcium channel blockers show no benefit in reducing cardiovascular events*

D.               The goal BP for this patient is <130/80 mmHg

E.                All the above statements are correct

10. A 42-year-old female with chronic obsctructive pulmonary disease is found on multiple office visits to have elevated BP measurements. Which of the following medications is contraindicated?

A.               Hydrochlorothiazide

B.               Metoprolol*

C.               Lisinopril

D.               None of the above

E.                All of the above

 

Real-life situations to be solved:

1.                 A 27-year-old female has hypertension that is difficult to control. She was diagnosed at age 25. Since that time she has been on increasing amounts of medication. Her current regimen consists of labetalol 1000 mg bid, lisinopril 40 mg qd, clonidine 0.1 mg bid, and amlodipine 5 mg qd. On physical examination she appears to be without distress. Her BP is 170/100, and HR is 84 bpm. Cardiac exam is unremarkable, without rubs, gallops, or murmurs. She has good peripheral pulses and has no edema. Laboratory studies reveal a potassium of 2.8 mEq/dL and a serum bicarbonate of 32 mEq/dL. Fasting blood glucose 114 mg/dL. What is the likely diagnosis?

A.     Congenital adrenal hyperplasia

B.     Fibromuscular dysplasia

C.     Cushing’s syndrome

D.     Conn’s syndrome

E.      Pheochromocytoma

2.                 A 20-year-old female is seen in the ED with symptoms of periodic headaches, sweating, and nausea with vomiting. She also complains of feeling light-headed with standing. Her BP on presentation is 230/135, with a HR of 92. On standing, the patient has BP of 205/100, with a HR of 136. On ophthalmologic examination the patient has mild blurring of the optic discs without hemorrhage. The examination is otherwise normal. What is the best medication for the management of this patient’s hypertension?

A.     Phentolamine

B.     Fenoldopam

C.     Esmolol

D.     Nicardipine

E.      Diazoxide

3.                 A 23-year old male seeks medical attention for the recent onset of headaches. The headaches are described as “pounding” and occur during the day and night. He has minimal relief with acetaminophen. Physical examination is notable for a BP of 185/115 mmHg in the right arm, a HR of 70/min, arteriovenous nicking on funduscopic examination, normal jugular veins and carotid arteries, reduced pulses in both lower extremities. Review of symptoms is positive only for leg fatigue with exertion. Additional measurement of BP reveals the following: Right arm 185/115, Left arm    190/115, Right thigh 100/60, Left thigh   105/60. What is the likely diagnosis?

A.     Congenital adrenal hyperplasia

B.     Fibromuscular dysplasia

C.     Cushing’s syndrome

D.     Pheochromocytoma

E.      Conn’s syndrome

 

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 iormal and hypertensive subjects.

2. Relevant terminology, definitions and classifications.

3. Chief complaints of cardiac patients.

4. Evaluation of basic signs and symptoms

5. Specific signs and symptoms.

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:

Real-life situations. 1.  – D. 2. – A . 3. – C

 

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: Secondary Hypertension

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

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

 

B – Additional:

1. Braunwald’s Heart Disease: a textbook of cardiovascular medicine (9^th ed.) / by Bonow R.O., Mann D.L., and Zipes D.P., and Libby P. eds. – Saunders, 2012. – 2048 p.

2. Braunwald’s Heart Disease: review and assessment (9^th ed.) / Lilly L.S., editor. – Saunders, 2012. – 320 p.

3. Cardiology Intensive Board Review. Question Book (2^nd ed.) / by Cho L., Griffin B.P., Topol E.J., eds. – Lippincott Williams & Wilkins, 2009. – 385 p.

4. Cleveland Clinic Cardiology Board Review / Griffin B.P., Kapadia S.R., Rimmerman C.M., eds. – Lippincott Williams & Wilkins, 2012. – 952 p.

5. Hurst’s the Heart (13^th ed.) / by Fuster V., Walsh R.A., Harrington R., eds. – McGraw-Hill, 2010. – 2500 p.

5. Oxford Handbook of Cardiology (2^nd ed.) / by Ramrakha P., Hill J., eds. – Oxford University Press, 2012. – 851 p.

 

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

Methodical instruction was discussed and adopted at the Department sitting 15.06.2009, Minute № 2

Methodical instruction was adopted and reviewed at the Department sitting 29.06.2010, Minute № 19

Methodical instruction was adopted and reviewed at the Department sitting 16.06.2011, Minute № 13

Methodical instruction was adopted and reviewed at the Department sitting 12.06.2012, Minute № 12

Methodical instruction was adopted and reviewed at the Department sitting 25.06.2013, Minute № 17