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METHODOLOGICAL INSTRUCTION:

June 11, 2024

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 № 1 (PRACTICAL – 6 HOURS)

Theme 1: Management of Patients with Chest Pain

Aim: to develop skills and to acquire experience relevant to management of patients presenting with chest pain.

Professional orientation of students. Chest pain 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 14.15-15.00 (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.

Choose the correct answer/statement

1. Combination lipid lowering therapy may be indicated:

A. To provide additional reduction of LDL-C

B. To achieve the goal for non-HDL-C

C. To treat severe hypertriglyceridemia

D. If it seems advisable, to raise HDL-C levels

E. All of the above*

2. What are the TG goals for patient based on AHA recommendations?

A. < 150 mg/dL*

B. < 200 mg/dL

C. < 300 mg/dL

D. None of the above

E. < 250 mg/dL

3. If the patient’s TG were 600 mg/dL, what would be your next step in lipid management?

A. Increase the HDL-H

B. Lower the LDL-C

C. Lower the TG*

D. Lower the TG and increase the HDL-C

E. Lower the non-HDL-C

4. What would you prescribe to a patient with TG – 600 mg/dL?

A. Raise the dose of atorvastatin to 40 mg/d

B. Add a fibrate *

C. Add niacin

D. Add ezetimibe

E. Increase the statin dose and add a fibrate

5. Choose the most appropriate fibrinolytic agent associated with the lowest intracranial hemorrhagic risk

A.Streptokinase *

B. Alteplase

C. Reteplase

D.Tenecteplase

E. None

6. ECG feature of ventricular aneurysm following MI is…

A. Persistent ST elevation *

B. Persistent ST depression

C. Persistent U wave

D. Inverted T wave

E. Tall “peaked” T waves

7. Which of the following is associated with ST segment elevation on ECG ?

A.Hypokalemia

B. Right ventricular hypertrophy

C. Digoxin effect

D.Early repolarization *

E. Subendocardial infarction

8. The followings are possible causes of prominent R wave in lead V₁ EXCEPT…

A.Posterior wall myocardial infarction

B. Right bundle branch block

C. Wrong lead connection

D.WPW syndrome, type A

E. Clockwise rotation of the heart *

9. Deep permanent Q waves may be seen in…. (choose one)

A. Early (hyperacute) phase anterior wall MI

B. WPW syndrome *

C. Established subendocardial infarction

D. Established acute phase posterior MI

E. Prinzmetal angina

10. Most of the deaths in myocardial infarction occur in the …. day

A. First *

B. Fifth

C. Seventh

D. Tenth

E. Twelfth

Real-life situations to be solved:

1. C. is an obese 54-yer-old man with peripheral arterial disease revealed by arterial duplex study. He denies exertional chest discomfort of dyspnea, but lives a fairly sedentary lifestyle. Physical exam reveals an obese man with normal BP, an unremarkable cardiac exam. His fasting lipids are as follows: TC 240 mg/dL, TG 250 mg/dL, HDL-C 35 mg/dL, LDL-C (calculated)155. Initial therapy should include:

A. TLC only

B. TLC plus a statin with a goal of reducing LDL-C to <130 mg/dL

C. TLC plus niacine or fibrate, with the goals of reducing LDL-C to <100 mg/dL and TG <150 mg/dL

D. TLC plus a statin with a goal of reducing LDL-C to <100 mg/dL

E. TLC plus a statin, as well as niacin or a fibrate, with the goals of reducing LDL-C to <100 mg/dL and TG <150 mg/dL

2. D. is a 71-year-old retired female whose father died at age 52 of a “massive MI”. She is very worried about her own risk of a heart attack. She watches her weight (BMI=23), does not smoke, and keeps physically fit. She denies angina or dyspnea on exertion, claudication, or history of TIA symptoms. Her fasting lipids are as follows: TC 250 mg/dL, TG 120 mg/dL, HDL-C 42 mg/dL, LDL-C (calculated)151. Initial therapy should include:

A. Nothing beyond her current lifestyle measures

B. Weight loss to bring BMI<20

C. TLC plus a statin to reduce LDL-C to <130

D. TLC to reduce LDL-C to <130

E. Statin plus a niacin to reduce LDL-C<130 and increase HDL-C>50 mg/dL

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 patients with CAD.

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.

8. Establish indications for surgical management in CAD.

Correct answers of test evaluations and situational tasks:

Real-life situations. 1 – B. 2 – 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: Management of Patients with Chest Pain

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.