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 № 3 (PRACTICAL – 6 HOURS)

 

Theme 3: Acute coronary syndrome: acute myocardial infarction

 

Aim: to develop skills and to acquire experience relevant to management of patients with acute coronary syndrome and acute myocardial infarction.

Professional Motivation: Acute myocardial infarction or angina is the usual initial presentation for coronary disease, although about 20 % of individuals with a coronary event do not even present to a hospital. For these individuals, sudden cardiac death is their initial manifestation of coronary disease. Unless defibrillation occurs within minutes, death ensues quickly. Fortunately, automated external defibrillators have become more available and are now found in many public places. Risk stratification in myocardial infarction is essential to determine appropriate therapy and for allocation of limited health care resources to high risk patients. In STEMI, the most important predictors of death include age, systolic blood pressure and heart rate at presentation, congestive heart failure and location of infarction. In NSTEMI high risk features, such as biomarker elevation or elevated TIMI risk score, can be used  to determine which patients should eligible for an early invasive strategy. 

 

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. With regard to secondary prophylaxis of MI, which of the following statements is FALSE?

A.               ACE-inhibitors have a favourable effect by many independent mechanisms

B.               Beta-blockers are important, if not contraindicated

C.               Statins have been shown to cause regression of atherosclerotic plaques

D.               Digoxin has been shown to have a favourable effect*

E.                Cardiac rehabilitation programs should not be forgotten

 

2. A 54-year old man with a history of hypertension presents with chest pain that started 2 hours ago and is diagnosed in the Emergency Department with anterior STEMI. His BP is 200/100 mmHg. He receives i.v. metoprolol and the BP falls to 170/85 mmHg. What is the most appropriate reperfusion strategy?

A.               Fibrinolytic therapy*

B.               Angiography and PCI

C.               Medical therapy alone and PCI at a later date

D.               CABG

E.                None of the above

 

3. A 75-year old woman presents to a community hospital (without invasive capabilities) with 6 hrs of chest pain and is diagnosed with inferior STEMI. The anticipated transfer to a medical center with primary PCI capability will take 2 hours. What is the preferred reperfusion therapy?

A.               Fibrinolytic therapy at presentation to the hospital *

B.               Transfer for angiography and PCI

C.               Half-dose fibrinolysis and GP IIb/IIIa inhibition at the presentation hospital and transfer for rescue PCI if it fails to produce reperfusion

D.               PCI at a later date

E.                CABG

 

4. A 48-year old man with an anterior STEMI receives fibrinolytic therapy with reteplase. Thirty min. after the second bolus he continues to have chest pain and his ECG demonstrates mild (estimated 30% resolution) of the ST segment elevations. What is the next correct step in his management?

A.               Readministration of a different fibrinolytic agent

B.               Administration of GP IIb/IIIa inhibitor

C.               Immediate coronary angiography and rescue PCI *

D.               Symptomatic relief of angina and heart failure

E.                Medical therapy and PCI at a later date

 

 

5. An 80-year old woman with chest discomfort for the last 15 hours and progressively worsening dyspnea over the last few hours presents to the Emergency Department and is diagnosed with anterior STEMI. What, if any, reperfusion strategy should be undertaken?

A.               Fibrinolysis

B.               Immediate coronary angiography and PCI

C.               Symptomatic relief of angina and heart failure *

D.               CABG

E.                None of the above

 

6. Post myocardial infarct, systolic murmur in the left lower sternum can be due to all of the following EXCEPT…

A.               Free wall rupture

B.               Complete heart block *

C.               Interventricular septum rupture

D.               Papillary muscle dysfunction

E.                Ischemic cardiomyopathy

 

7. Myocardial infarction most often results in…

A.               Mitral stenosis

B.               Aortic regurgitation

C.               Aortic stenosis

D.               Mitral regurgitation *

E.                Tricuspid regurgitation

 

8. Death in cases of papillary muscle rupture is due to…

A.               Cardiac arrhythmias

B.               Ventricular aneurysm

C.               Coronary insufficiency

D.               Pulmonary edema *

E.                Cardiac tamponade

 

9. Right ventricular infarction is associated with all of the following EXCEPT…

A.               Cardiomegaly

B.               Arrhythmia

C.               Hypotension

D.               Normal JVP *

E.                All the statements are true

 

10. In right ventricular infarction, the following additional therapy is given…

A.               i.v. fluids *

B.               Calcium gluconate

C.               Restriction of fluids

D.               Lithium carbonate

E.                Nitroprusside

 

Real-life situations to be solved:

1. A 77-year old woman with a history of GERD presents in the first hour of an acute inferior STEMI. The BP is normal. Invasive facilities are not readily available. What is the preferred strategy for reperfusion therapy?

A.               Fibrinolytic therapy

B.               Transfer for immediate coronary angiography and PCI

C.               Half-dose fibrinolysis and GP IIb/IIIa

D.               Symptomatic relief of angina only

 

2. A 50-year old man presents to the emergency room about 1.5 hrs after the onset of chest pain. An ECG showed 3 mm ST elevation in the anterior and lateral leads. Which of the following statements regarding his management is correct?

A.               Primary PCI is recommended over thrombolytics because PCI has short-term mortality benefit, reduced reinfarction risk, and reduced risk of stroke

B.               Thrombolysis is recommended because door-to-baloon time is >90 min.

C.               Half-dose thrombolysis should be recommended; then the patient should be transferred for PCI.

D.               The patient should be referred for emergency CABG for better survival advantage.

 

3. A 65-year old woman developed cardiogenic shock 10 hrs after presenting with anterior wall MI. The most appropriate management strategy is….

A.               Administration of thrombolytics

B.               Watchful waiting after initiation of inotropic support and insertion of an intra-aortic balloon pump

C.               Coronary angiography with revascularization within 18 hrs of shock onset

D.               Coronary angiography with revascularization within 24 hrs of shock onset

 

4. A 62-year old woman, current smoker, diabetic, hypertensive and hyperlipidemic, presented to the ER with a 2 day history of intermittent chest pain. The patient does not have any signs of heart failure. An ECG showed 2-mm depression in V2-V6. The coronary angiogram showed 90% stenosis in the proximal third of the LAD, 80% stenosis in the proximal RCA, with 30% disease in the middle circumflex artery. The best plan of treatment for this patient is

A.               PCI to both the LAD and RCA now

B.               Referral for two-vessel CABG

C.               PCI to the LAD with staged intervention to the RCA

D.               Medical management with no PCI or CABG

 

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 CAD patients.

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. A 2. D 3. B 4. 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: ACUTE CORONARY SYNDROMES

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