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 № 2 (PRACTICAL – 6 HOURS)
Theme 2: Management of patients with arrhythmias. Cardiac pacing, electrical cardioversion: indications and technique.
Aim: to develop skills and to acquire experience relevant to management of patients with arrhythmias.
Professional orientation of students. There are various different types of arrhythmias ranging from almost harmless to very serious. Correct diagnosis of the specific subtype and any underlying condition is extremely important. Cardiac pacing is the only definitive therapy for symptomatic bradycardia.
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.
Choose the correct answer/statement:
1. Wenckebach phenomenon is defined as…
A. Progressive lengthening of PR interval till a beat is dropped
B. Slurred QRS complex
C. Irregular heart rate and PVC’s
D. Shortened QT intervals
E. Widening QT intervals
2. Which of the following electrocardiographic (ECG) abnormalities is NOT typically associated with the Brugada pattern?
A. Downsloping ST-segment elevations in V1-V3
B. QRS morphology resembling a right bundle branch block (RBBB)
C. Negative deflection of the T-wave in the affected precordial leads
D. Prolonged QT interval
E. None of the above
3. Which of the following is not a therapeutic consideration in the management of the patient with atrial flutter?
A. Control of the ventricular response
B. Conversion to a normal sinus rhythm
C. Coronary artery catheterization
D. Prevention of recurrent episodes
E. Prevention of thromboembolic complications
4. Which of the following medications is not typically used for pharmacologic cardioversion?
A. Procainamide
B. Furosemide
C. Dofetilide
D. Ibutilide
E. Amiodarone
5 : A 59-year-old male experiences palpitations and presents to the emergency room, where the following rhythm strip is obtained, demonstrating
a. Normal sinus rhythm
b. Junctional rhythm
c. Atrial flutter with 4:1 atrioventricular block
d. Paroxysmal atrial tachycardia with 2:1 atrioventricular block
e. Premature atrial contractions
6-10. Match the tracings with the correct interpretation:
6.
7.
8.
9.
a. Normal Sinus Rhythm
b. Ventricular Fibrillation
c. Atrial Fibrillation
d. Wandering Atrial Pacemaker
e. Ventricular Tachycardia
10. An 80-year-old is found to have left bundle branch block on ECG. On cardiac auscultation, which of the following is the most likely finding?
A. Fixed (wide) split S2
B. Paradoxical (reversed) split S2
C. S3
D. S4
E. Opening snap
Real-life situations to be solved:
A. Normal sinus rhythm
B. Junctional rhythm
C. Atrial flutter with 4:1 atrioventricular block
D. Paroxysmal atrial tachycardia with 2:1 atrioventricular block
E. Complete heart block
On physical examination, blood pressure is 102/60 mm Hg and heart rate is 40/min. Cardiac examination shows S1 that varies in intensity and is occasionally booming. The rest of the findings are normal. A rhythm strip from her electrocardiogram is shown.
What is the most likely cause of bradycardia in this patient?
A. Excess vagal tone
B. Autonomic dysfunction
C. Congenital complete heart block
D. Use of the drug “ecstasy”
E. Sick sinus 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 in patients with arrhythmias.
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 – A. 2 – D. 3-C. 4-B. 5-C. 6-E. 7-C. 8-A. 9-D. 10-B
Real-life situations.
References.
A – Basic:
1. Davidson’s Principles and practice of medicine (21st revised ed.) / by Colledge N.R., Walker B.R., and Ralston S.H., eds. – Churchill Livingstone, 2010. – 1376 p.
2.
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 Arrhythmias. Cardiac pacing, electrical cardioversion: indications and technique.
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 (9th 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 (9th ed.) / Lilly L.S., editor. – Saunders, 2012. – 320 p.
3. Cardiology Intensive Board Review. Question Book (2nd ed.) / by Cho L.,
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 (13th ed.) / by Fuster V., Walsh R.A., Harrington R., eds. – McGraw-Hill, 2010. – 2500 p.
5. Oxford Handbook of Cardiology (2nd ed.) / by Ramrakha P., Hill J., eds. – Oxford University Press, 2012. – 851 p.
Methodical instruction has been worked out by: R. Komorovsky, MD
Methodical instruction was discussed and adopted 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
