Methodical Instruction

METHODICAL INSTRUCTION FOR STUDENTS OF THE 6 COURSE

FOREIGN STUDENTS’ FACULTY

Module 3. Current practice in internal medicine

Content module 1. Management of patients with cardiovascular disorders

LESSON № 5 (PRACTICAL – 6 HOURS)

 

Theme 5: Management of patients with dyspnea and heart failure

 

Aim: to develop skills and to acquire experience relevant to management of patients with acute and chronic heart failure. One should have an understanding of the definition of heart failure, how the syndrome begins, the various hemodynamic profiles that emerge, the underpinnings of myocardial remodeling, how the periphery is affected, and the important prognostic features. One should also be able to draft a treatment plan for patients with heart failure, taking into account the complexity of the syndrome, including comorbid conditions, presence or absence of systolic dysfunction and its severity, symptomatology and etiology.

Professional orientation of students. Heart failure has been termed the “new epidemic of cardiovascular disease” for the 21^st century. It is the single most common reason for patients over 65 years to be admitted to the hospital. Mortality rates from acute coronary syndromes have decreased resulting in an increase in the prevalence of patients surviving with chronic coronary disease and ventricular dysfunction. In combination with the aging of the population, the effect of decreasing acute mortality from myocardial infarction has led to an increase of prevalence of heart failure. This trend is expected to continue.

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. Choose the correct answer/statement:

1.                 B-type natriuretic secretion is regulated by:

A.                                       Fluid accumulation in the lungs

B.                                       Pressure and volume of the left ventricle

C.                                       Oedema in the anckles

D.                                       Auricular end diastolic pressure

E.                                        All of the above

2.                 Which of the following statements are true ?

A.                                       A normal resting ECG is rare in angina pectoris

B.                                       A normal resting ECG is common in heart failure

C.                                       Cardiomegaly plus pleural effusions make heart failure very likely

D.                                       Atrial fibrillation commonly does not cause dyspnoea in patients with LVH and diastolic dysfunction

E.                                        All of the above

3.                 The value of BNP in the diagnosis of heart failure in the emergency room in patients with acute dyspnoea:

A.                                       Is supported by a BNP concentration >100 pg/ml

B.                                       Is excluded by a NT-proBNP concentration <1000 pg/ml

C.                                       Is restricted to patients without a previous history of heart failure

D.                                       Has not been evaluated in patients with renal dysfunction

4.                 Which symptoms/signs only occur when the HF is relatively advanced – that is, they are commonly absent in mild heart failure

A.                                       Cardiomegaly on chest X-ray

B.                                       Orthopnea

C.                                       Exertional dyspnea

D.                                       A abd B

E.                                        B and C

5.                 All patients with heart failure should be advised to:

A.                                       Refrain from smoking

B.                                       Restrict sodium intake

C.                                       Avoid a flu shot

D.                                       A and B

E.                                        All of the above

6.                 Exercise training in chronic heart failure

A.                                       Has been shown to increase peak oxygen consumption by 15-20% in randomized controlled trials

B.                                       Has been shown to increase LV ejection fraction by 15-20% in randomized controlled trials

C.                                       Is not recommended in heart failure

D.                                       Has never been shown to reduce mortality and morbidity

7.                 Drugs that should be avoided in heart failure patients are:

A.                                       Non-steroidal anti-inflammatory drugs (NSAIDS)

B.                                       Corticosteroids

C.                                       Beta-blockers

D.                                       A and B

E.                                        All of the above

8.                 The followings improve the survival figure in chronic congestive heart failure as shown by many studies…EXCEPT

A.                                       Bisoprolol

B.                                       Metoprolol succinate

C.                                       Atenolol

D.                                       Spironolactone

E.                                        Carvedilol

9.                 The following drugs have significantly improved survival in HF patients

A.                                       ACE inhibitors

B.                                       Nitrates

C.                                       Digoxin

D.                                       Diuretics

E.                                        All of the above

10.            Which of the statements about beta-blocker treatment in HF is true?

A.                                       Randomised clinical trials show that b blockers are beneficial in patients with heart failure and preserved left ventricular function

B.                                       Elderly patients are the most frequently studied population in  blocker trials

C.                                       Blockers exert a favourable effect in heart failure due to ischaemic and non-ischaemic aetiology

D.                                       Patients with diabetes should always be excluded from blocker treatment

E.                                        There is clear evidence that end stage heart failure patients should be treated with blockers

 

Real-life situations to be solved:

1. A 56-year-old man presents to your clinic for follow-up after being discharged from the hospital 6 weeks ago. He underwent successful primary angioplasty for acute anterior MI; however his EF is now 40%. He is currently taking simvastatin (Zocor), aspirin, clopidogrel (Plavix), metoprolol tartrate (Corvitol), and losartan (Cozaar). He states that he cannot afford all of these medications. He would like to know which medications are essential for longer life. Which medications should you tell him are essential?

2. A 78-year-old woman with chronic heart failure (EF 25%), chronic atrial fibrillation, gastroesophageal reflux disease, hypertension, hyperlipidemia, diabetes, and osteoporosis takes 12 different pills. Recently a nurce has told her that she does not need to take digoxin because she is on amiodarone. She wants to eliminate digoxin from her medication regimen, and she wants to know why you put her on it in the first place. What is your answer?

3. A 24-year-old female medical student presents to urgent care with 5 days of fever and shortness of breath. She is diagnosed with viral infection and sent home. Five months later during her physical examination class, she is found to have an S3 by her fellow students. She presents to your office for a second opinion. On examination, she appears healthy and io distress. Her BP is 95/50 mmHg, with an HR of 71 bpm and a respiratory rate of 12. her neck veins are not distended, and her examination is unremarkable except for an enlarged heart. You do not appreciate an S3. You order a TTE, which shows an EF of 20% with a dilated heart. There is no valvular abnormality. Which of the following is your recommendation?

 

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 heart failure.

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:

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

Real-life situations. 1. all of them except losartan 2. digoxin reduces hospitalization rate. 3. begin an ACE inhibitor and beta-blockers. She has well compensated cardiomyopathy. Only medications that prolong life needs to be started. She does not need medication for symptom relief; therefore, ACE inhibitor and beta-blockers should be started.

 

References.

А – 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:  Management of Patients with Heart Failure and Dyspnea

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 assoc. prof. Komorovsky R.R.

Methodical instruction was discussed and adopted at the Department sitting 29.06.2010, protocol № 19  

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

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

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