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 № 9 (PRACTICAL – 6 HOURS)

Theme 9: Cor pulmonale and pulmonary embolism

Aim: to develop skills and to acquire experience relevant to management of patients with pulmonary embolism and chronic cor pulmonale as well as to identify patients at risk for pulmonary embolism and to provide them adequate thromboprophylaxis.

Professional Motivation: pulmonary embolism is a common problem in hospitalized patients, with a prevalence rate of about 1%. It is frequently not adequately diagnosed. Although it is the immediate cause of death in about 10% of patients who die in U.S. hospitals, pulmonary embolism is detected in 30% of routine autopsies. The correct antemortem diagnosis is made in less than 30% of cases. Mortality from pulmonary embolism has not diminished over the past 20 years. Deep venous thrombosis is the cause of pulmonary embolism in more than 90% of patients. The risk of pulmonary embolism from untreated proximal deep venous thrombosis is 50% and mortality from untreated pulmonary embolism is 8%. Approximately 10% of symptomatic pulmonary embolisms are fatal within the first hour. The highest risk for a postoperative pulmonary embolism occurs 3 to 7 days following surgery. Chronic pulmonary hypertension and cor pulmonale develop in 3.8% of all pulmonary embolism patients by 2 years after the initial event.

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 Question. Choose the correct answer/statement

1.  What is NOT a cause of  chronic cor pulmonale?

 A. COPD

B. Recurrent pulmonary emboli

C. Mitral stenosis

D. Kyphoscoliosis

2.All of the following statements with regard to primary endocardial fibroelastosis (EFE) are correct EXCEPT:

A.               The condition is often familial

B.               The mitral and aortic valve leaflets are usually thickened and distorted

C.               The murmur of mitral stenosis is the most common auscultatory finding

D.               Symptoms of primary EFE usually develop between 2 and 12 months of age

E.                Echocardiographic features include a reduced ejection fraction and increased left atrial and left ventricular dimensions

3.Which of the following therapies improves survival in patients with cor pulmonare secondary to COPD?

A.               Digoxin

B.               Oxygen

C.               Beta-adrenergic agonists

D.               Theophylline

E.                Hydralazine

4.What is NOT a cause of chronic cor pulmonale?

A.                COPD

B.                 Recurrent pulmonary emboli

C.                 Mitral stenosis

D.                Kyphoscoliosis

E.                 Obstructive sleep apnea

5.Which of the following conditions is associated with increased left ventricular preload?

A.               Sepsis

B.               Right ventricular infarction

C.               Mitral regurgitation

D.               Dehydration

E.                Pulmonary embolism

6.Each of the following conditions is associated with the development of pulmponary edema EXCEPT:

A.               Increased pulmonary venous pressure

B.               High altitude

C.               Increased plasma oncotic pressure

D.               Eclampsia

E.                Heroin overdose

7.The statements about the diagnosis of PE include all of the following EXCEPT:

A.               Arterial blood gas measurement is often unhelpful in the diagnosis of acute PE

B.               The most common ECG finding in patients with PE is sinus tachycardia

C.               Pulmonary infarction due to PE can be visualized on a standard chest radiograph

D.               Reduced intensity of the pulmonic component of the second heart sound is typical in patients with large PE

E.                Fibrin-degradation products (e.g., D-dimer) are commonly elevated in patients with PE

8.Heart failure is:

A.               Decreasing in incidence and prevalence due to recent advances in the treatment of cardiovascular disease

B.               One of the diagnoses with the highest readmission rate

C.               A common condition across all ages

D.               Can be diagnosed from a clinical response to treatment

E.                All of the above statements are correct

9.According to the ESC guidelines, the following patients have heart failure:

A.               An obese, dyspnoeic lady with swollen anckles but a normal echocardiogram

B.               An asymptomatic man with a previous MI and area of hypokinesis on his echocardiogram

C.               A hypertensive man with LVH, fast atrial fibrillation and dyspnea

D.               An elderly man with a few basal crepitations but a normal echocardiogram

E.                All of the above

10.Which of the following sometimes occur when heart failure is absent?

A.               Gallop rhythm

B.               Anckle oedema

C.               A past history of a MI

D.               B and C

E.                A, B, and C

 

Real-life situations to be solved:

1. A 35-year-old man with a history of hypertension presents to the ER in respiratory distress. He is intubated in the ER for respiratory distress. His BP is 70/50 mmHg, his HR is 130 bpm, and his respiratory rate is 20. He is taken to the medical ICU, and a PA catheterization is performed. His hemodynamics indices are as follows: RA pressure, 22 mmHg; PA pressure, 20/10 mmHg; cardiac output, 3.5 L/min/m²; PCWP, 12 mmHg; and systemic vascular resistance, 1,690 dyne/sec/cm⁵. What is your diagnosis?

2. A 53-year-old woman with a history of chronic heart failure presents to the ER. She is cool and clammy. She reports being short of breath. Her BP is 70/40 mmHg, her HR is 110 bpm, and her respiratory rate is 30. She has elevated neck veins and a prominent S3. Her ECG shows sinus tachycardia. She is admitted to the CCU with heart failure. A PA catheterization is performed, and her hemodynamics indices are as follows: RA pressure, 12 mmHg; PA pressure, 62/30 mmHg; cardiac output, 1.9 L/min/m²; PCWP, 36 mmHg; and systemic vascular resistance, 2,000 dyne/sec/cm⁵. What is your next step?

3. A 73-year-old male with a long history of diabetes, cigarette smoking and hypertension is admitted to the hospital with shortness of breath, near syncope, and hypotension. A Swan-Ganz catheter is placed and reveals a PA pressure of 42/22 mmHg, cardiac output of 1.3 L/min/m², PCWP of 5 mmHg. The patient most likely has.

 

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. Cardiovascular and pulmonary anatomy

2.Cardiovascular and pulmonary physiology and pathology

3. History taking, inspection and physical examination of cardiovascular patients.

4. Principles of laboratory and instrumental evaluation of cardiovascular patients.

 

Student 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 of pulmonary embolism, including unstable angina pectoris and myocardial infaction; pneumonia; chronic obstructive pulmonary disease (COPD), bronchitis; congestive heart failure; pericarditis; pneumothorax; costochondritis.

7. Prescribe the appropriate therapy, incl. that for thromboprophylaxis

 

Correct answers of test evaluations and situational tasks:

Real-life situations. 1. acute RV failure: the patient’s hemodynamic pressures are characteristic of acute RV failure and he needs aggressive fluid resuscitation. 2. start dopamine. This patient is in cardiogenic shock. She needs BP support before all else. In these patients, dopamine is the first line of choice, followed by norepinephrine. If there is no change with dopamine and norepinephrine, then dobutamine may be added while the patient is being prepared for IABP placement. 3. cor pulmonale.

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

 

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: Cor Pulmonale and Pulmonary Embolism

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.

2. 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.

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

4. 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.

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

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

7. 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