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 № 6 (PRACTICAL – 6 HOURS)

Theme 6: Management of patients with acquired valvular heart diseases 

Aim: to develop skills and to acquire experience relevant to management of patients with acquired valvular heart disease.

Professional orientation of students. Aortic stenosis is one of the most frequent valve pathologies encountered in clinical cardiology. Aortic insufficiency most often results from infective endocarditis, trauma, or aortic dissection. Mitral valve disease is a common valvular abnormality, resulting from various etiologies and having well-understood, varied clinical manifestations. Tricuspid valve disease is less common, occurring most often as a functional result of left-sided heart disease and/or pulmonary hypertension.

 

 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 of acquired valvular heart diseases.

3. Main clinical findings in patients with acquired valvular heart diseases.

4. Main laboratory and instrumental findings in patients with acquired valvular heart diseases.

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 cause of tricuspid regurgitation in an adult population?

A. Rheumatic tricuspid disease

B. Carcinoid

C. Congenital abnormalities

D. Pulmonary hypertension resulting from primary left-sided disease

E. Myxomatous disease of the tricuspid valve

2. Which of the following patients with severe chronic mitral regurgitation (MR) is not a surgical candidate?

 A. NYHA functional class III, EF 40%

B. NYHA functional class I, EF 70%, LV end systolic diameter 35 mm

C. NYHA functional class II, EF 50%

D. NYHA functional class II, EF 70%, LV end systolic diameter 42 mm

 3. A 52-year-old woman is referred for shortness of breath. Her clinical examination shows a 2/6 diastolic murmur along the left sternal border and a wide pulse pressure. The patient has no signs of heart failure but has a third heart sound and a soft systolic murmur of MR.

In patients with a barely audible diastolic murmur and heart failure, what sign is suggestive that severe aortic regurgitation (AR) is the cause of heart failure?

A. A third heart sound

B. A murmur of functional MR

C. An increased second heart sound

D. A BP of 130/45 mmHg

E. A decreased first heart sound

 4. A 32-year-old woman has known MS. She is able to exercise daily for 45 min. without symptoms. Six months ago she had a TTE that showed a mean gradient of 5 mmHg, MVA of 1.6 cm², and a PAP of 30 mmHg. She wants to get pregnant. What would you recommend?

 A. Repeat TTE

B. TEE

C. PMBV

D. MVR

E. Proceed with pregnancy with beta blockade as necessary

5. Acute Aortic regurgitation is seen in all the following except:

A.   Acute myocardial infarction

B.   Marfan’s syndrome

C.   Bacterial endocarditis

D.   Ankylosing spondylitis

E.    Posttraumatic Aortic aneurism

6. All of the following murmurs may be heard in patients with aortic regurgitation except:

A.   Pansystolic murmur

B.   Austin flint murmur

C.   High-pitched decrescendo diastolic murmur.

D.   Soft, low pitched mid distolic rumbling murmur

E.    Mid-systolic ejection flow murmur

7. Differential diagnosis of mitral stenosis and

A.   Left atrial myxoma

B.   Ebstein anomaly

C.   Aortico pulmonary window

D.   Atrial septal defect

E.    Ventricle septal defect

8. First heart sound is soft in all, except:

A.   Short PR interval

B.   Ventricular septal defect

C.   Mitral regurgitation

D.   Calcified valve

E.    Dilatation of left ventricle

9. Following is true regarding opening snap:

A.   It is a high-pitched diastolic sound.

B.   It is due to opening of stenosed aortic valve.

C.   It indicates pulmonary arterial hypertension

D.   It preceedes the aortic component of second heart sound.

E.    Heard in systole

10. Graham Steel murmur occurs in:

A.   pulmonary regurgitation

B.   aortic stenosis

C.   aortic regurgitation

D.   mitral regurgitation

E.    tricuspid regurgitation

 

Real-life situations to be solved:

 1. A 32-year-old male with known bicuspid aortic valve is referred to you for management of aortic insufficiency. He is completely asymptomatic and jogs 3 miles a day as well as doing other aerobic exercise for 30 minutes daily. An echocardiogram reveals a mildly dilated LV (EDD of 60 mm) with an EF of 65%. There is prolapse of conjoined aortic leaflet with 3-4+ insufficiency. What is your recommendation?

 2. What do you tell him is his yearly risk of sudden death?

 3. If, in the above patient, echocardiographic evaluation revealed an ascending aortic root dimension of 5.1 cm, what would you recommend?

 

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 acquired valvular heart diseases.

2. Relevant terminology, definitions and classifications of acquired valvular heart diseases.

3. Chief complaints of patients with acquired valvular heart diseases.

4. Evaluation of basic signs and symptoms of patients with acquired valvular heart diseases.

5. Specific signs and symptoms of acquired valvular heart diseases.

6. Methods of physical examination of patients with acquired valvular heart diseases.

7. Methods of laboratory evaluation of patients with acquired valvular heart diseases.

8. Methods of instrumental evaluation of patients with acquired valvular heart diseases.

9. Principles of management of patients with acquired valvular heart disease.

 

Students should be able to:

1. Perform a clinical exam of patients with acquired valvular heart disease.

2. Reveal main clinical syndromes of acquired valvular heart disease.

3. Draft a plan of laboratory and instrumental evaluation of patients with acquired valvular heart disease.

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

Real-life situations. 1. Observation with a close follow up (closer than 3 years). The patient is asymptomatic with a good functional capacity. He has a normal ejection fraction with a mildly dilated left ventricle (LV). There is no role for cardiac catheterization at this juncture.

2. From the available published literature, as summarized in the ACC/AHA consensus guidelines, the risk is about 0.2% per year in those asymptomatic patients with preserved LV function

 3. Referral for surgery. An aortic dimension >5.0 cm (or growth >0.5 cm per year) in a patient with bicuspid aortic valve is a class I indication for surgery.

 

References.

А – 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 edition) (With studenconsult Online Access) / Edited by P. Kumar, M. L. Clark. – London : Elsevier Health Sciences, 2012. – 1304 p.

4.       Web -sites:

www.tdmu.edu.ua: Management of patients with acquired heart diseases

 

 

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. Valvular Heart Disease / B. W. Andrus, J. C. Baldwin. – London : Manson Publishing Ltd., 2010. – 176 p.

5. Valvular Heart Disease in Clinical Practice / Edited by M. Y. Henein. – England : Springer London Ltd., 2009. – 179 p.

6. Clinical Echocardiography (2 revised edition) / Edited by M. Y. Henein.. – England : Springer London Ltd., 2012. – 328 p.

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

8. ESC/EACTS GUIDELINES. Guidelines on the management of valvular heart disease (version 2012) // European Heart Journal. – 2012. – №33. – 2451-2496 р. 

9. Web -sites:

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

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

 

Methodical instruction has been worked out by assoc. prof. Komorovsky R.R.

Methodical instruction was discussed and adopted at the Department sitting “27” August, 2013. Minute № 1