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 № 6 (PRACTICAL – 6 HOURS)

 

Theme 6: Adult Congenital Heart Disease

 

Aim: to develop skills and to acquire experience relevant to management of patients with adult congenital heart disease: atrial septal defect (ASD), ventricular septal defect (VSD), patent ductus arteriosus (PDA), aortic coarctation (CoA), Eisenmenger syndrome.

Professional Motivation: adults with congenital heart disease (CHD) are a rapidly growing population of patients, owing to advances in the diagnosis and treatment of children with CHD. Most children with CHD are now expected to survive to adulthood, either with or without the aid of surgical correction or palliation. According to recent estimates, there are now nearly three quarters of a million adults with CHD, and these numbers continue to rise with further advancements in diagnosis and therapy. Although ideally served by cardiologists with advanced training in adult CHD, most of these patients receive the majority of their care from primary care physicians and general cardiologists, even though very few cardiology training programs have a formalized adult CHD curriculum. Being aware of the often unique clinical presentations, and having a general understanding of the anatomy and the pathophysiologic consequences of CHD is vital for the timing of percutaneous, electrophysiologic, and surgical interventions.

 

 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.  What is the most common coexisting congenital anomaly in patients with coarctation of the aorta?

 A. Cleft mitral valve

B. Bicuspid aortic valve

C. Ebstein’s anomaly

D. Ventricular septal defect

E. Patent ductus arteriosus

 2. Patients with Eisenmenger’s syndrome should avoid all of the following, EXCEPT:

A. Dehydration

B. High altitude

C. Heavy exertion

D. Vasodilators

E. Phlebotomy

 3. Bacterial endocarditis prophylaxis is indicated in all adults who have the following congenital heart diseases, EXCEPT:

A. VSD

B. Coarctation of the aorta

C. Secundum ASD

D. Hypertrophic obstructive cardiomyopathy

E. PDA

 4. All of the following physical examination findings are associated with ostium secundum ASD, except:

 A. Precordial heave

B. Fixed split S2

C. Lateral and inferior displacement of the apex beat

D. Soft systolic ejection murmur in the second left intercostal space

E. Normal S1

 5. A 30-year-old man with Eisenmenger’s syndrome and irreversible pulmonary hypertension caysed by untreated VSD is at risk for developing symptoms and signs of hyperviscosity. All of the following are associated with hyperviscosity syndrome, EXCEPT:

A.  Paresthesias

B.   Erythrocytosis    

C.   Coronary artery ectasia

D.   Thrombosis and bleeding

E.    Visual disturbances

6. All of the following are characteristic findings of ostium primum atrial septal defect (ASD), EXCEPT:

A.  Precordial heave

B.   Fixed split S2

C.   Right axis deviation

D.  Systolic ejection murmur

E.   Prominent pulmonary vascular markings on CXR

7. All of the following are indications for surgical closure of an ASD, EXCEPT:

A.  Significant symptoms in a 65-year-old

B.   RV dysfunction

C.   Pulmonary vascular resistance >15 Wood units that does not diminish with vasodilators

D.  An asymptomatic 20-year-old with a Qp/Qs of 1,7 with no pulmonary hypertension

E.   RV enlargement

8. All of the following are associated with hyperviscosity in the setting of Eisenmenger’s syndrome EXCEPT:

A.  Coronary artery ectasia

B.   Erythrocytosis

C.   Visual disturbances

D.  Paresthesias

E.   Thrombosis and bleeding

9. All of the following statements regarding patent ductus arteriosus (PDA) are true EXCEPT:

A.  The majority of cases close spontaneously after infancy

B.   There is a higher incidence in mothers who acquired rubella during pregnancy

C.   A decrease in the duration and intensity of the murmur has a poor prognostic implication

D.  Left ventricular hypertrophy precedes RV hypertrophy

E.   If it is uncorrected, approximately one third of patients die by the age of 40 years

10. Choose the congenital disorder compatible with the following chest radiography findings: marked cardiomegaly, severe right atrial enlargement, and normal lung fields:

A.  Eisenmenger’s syndrome

B.   Coarctation of the aorta

C.   PDA

D.  Ebstein’s anomaly

E.   Tetralogy of Fallot

 

Real-life situations to be solved:

 1. A 28-year-old woman is referred to you for evaluation of a heart murmur. She states she is a long-distance runner and has not noted any significant symptoms. On examination you note very brisk pulses and her BP is 100/40 mmHg. Her murmur extends from systole into diastole and there is near “machinery”-type quality to it. The remainder of her physical exam is essentially unremarkable, as is her bloodwork. The most likely cardiac anomaly in this case is…

 2. You have been asked to see a 45-year-old woman with a VSD. She has been in excellent health for many years and voices no particular complaints. She had been taking antibiotis prophylaxis with dental procedures but discontinued this as a result of the recent guideline changes. On examination she has a III/VI pansystolic murmur and normal intensity S1 and S2. Her lungs are clear and she has no jugular venous distension. All of the following characteristics would argue for a benign clinical course in this case EXCEPT

         A. a loud murmur

B. normal intensity heart sounds

C. a supracrystal (or subaortic) morphology

D. the absence of right or left heart enlargement

E. all are benign characteristics

 3. A 25-year-old man is referred to you for an abnormal heart sound. The patient is asymptomatic and very active. He has a continuous murmur at the left upper sternal border. A TTE reveals a small PDA with normal LV and RV and normal pulmonary pressures. How would the patient be best managed?

 

 

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 adult congenital heart disease.

2. Relevant terminology, definitions and classifications of adult congenital heart disease.

3. Chief complaints of patients with adult congenital heart disease.

4. Evaluation of basic signs and symptoms of patients with adult congenital heart disease.

5. Specific signs and symptoms of adult congenital heart disease.

6. Methods of physical examination of patients with adult congenital heart disease.

7. Methods of laboratory evaluation of patients with adult congenital heart disease.

8. Methods of instrumental evaluation of patients with adult congenital heart disease.

9. Principles of management of patients with adult congenital heart disease.

 

Students should be able to:

1. Perform a clinical exam of patients with adult congenital heart disease.

2. Reveal main clinical syndromes of adult congenital heart disease.

3. Draft a plan of laboratory and instrumental evaluation of patients with adult congenital heart disease.

4. Assess the results of laboratory and instrumental evaluation of patients with adult congenital heart disease.

5. Diagnose the condition and formulate the diagnosis according to current classification.

6. Perform differential diagnosis of patients with adult congenital heart disease.

7. Prescribe the appropriate therapy to the patients with adult congenital heart disease.

 

 Correct answers of test evaluations and situational tasks:

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

Real-life situations. 1. patent ductus arteriosus 2. C: of the various types of VSD’s, supracristal (subaortic) defects should be monitored closely because of their predilection for spontaneous closure by aortic leaflet tissue, which can result in significant aortic regurgitation. 3. ligation or closure of the PDA.

 

References.

A – Basic:

1.                 Davidson’s Principles and Practice of Medicine (1st Edition) / Edited by N. R. Colledge, B. R. Walker, S. H. Ralston. – Philadelphia : Churchill Livingstone, 2010. – 1376 p.

2.                 Harrison’s Principles of Internal Medicine / Dan L. Longo, A. S. Fauci, D. L. Kasper [et al.]. – New York : McGraw-Hill, 2011. – 4012 p.

3.                 Kumar and Clark’s Clinical Medicine (8th Revised ed.) (With STUDENTCONSULT Online Access) / Edited by P. Kumar, M. L. Clark. – London : Elsevier Health Sciences, 2012. – 1304 p.

4.     Web -sites:

a)     www.tdmu.edu.ua: Adult Congenital Heart Disease

b)    http://emedicine.medscape.com/cardiology

c)      http://meded.ucsd.edu/clinicalmed/introduction.htm

 

B – Additional:

1. Braunwald’s Heart Disease Review and Assessment  / L. S. Lilly. – Philadelphia : Elsevier – Health Sciences Division, 2012. – 320 p.

2. Cleveland Clinic Cardiology Board Review / by Cho L., Griffin B.P., Topol E.J., eds. – Lippincott Williams & Wilkins, 2009. – 385 p.

3. Oxford Handbook of Cardiology (2nd Revised edition) / Edited by P. Ramrakha, J. Hill. – Oxford : Oxford University Press, 2012. – 880 p.

4. Mayo Clinic Cardiology: Concise Textbook  (4^rd ed.) / by Murphy J.G., Lloyd M.A., eds. – New York : Oxford University Press Inc., 2012. – 1608p.

5. ESC Guidelines for the management of grown-up congenital heart disease (2010) // European Heart Journal. – 2010. – №31. – 2915–2957 p.

6. Warnes et al. ACC/AHA 2008 Guidelines for the Management of Adults With Congenital Heart Disease: Executive Summary J Am Coll Cardiol 2008:52:e143-e263.

 

 

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