METODOLOGICAL 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 № 4 (PRACTICAL – 6 HOURS)

 

Theme 4 : Management of patient with cardiomegaly (cardiomyopathy).

 

Aim: the improvement of the skills in determination the doctors’ tactics in cardiomegaly; to develop differential diagnosis of the cardiomegaly caused by myocarditides, pericarditis and cardiomyopathy; to determine differential approaches to their treatment.

 Professional orientation of student : During the last years considerable interest arised to the problem of non-ischemic heart disease. The list of non-ischemic heart diseases broadened due to considerable achievements of theoretical and practical cardiology, the mechanisms of their development were specified and the methods of diagnostics and treatment continue to be perfected. About 20 % non-ischemic heart diseases are due tomyocarditis. Modern instrumental methods of diagnostics and therapy substantially improved the possibilities of diagnosis and treatment/

 

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. Cardinal manifestations of many forms of acute pericarditis may be all of the following except:

A.               pain

B.               pericardial friction rub

C.               migratory polyarthritis

D.               pericardial effusion with cardiac tamponade

E.                paradoxic pulse.

2. When pericardial friction rub can be elicited?

A.               when firm pressure with the diaphragm of the stethoscope is applied to the chest wall with a patient sitting up

B.               when firm pressure with the diaphragm of the stethoscope is applied to the chest wall with a patient leaning forward

C.               when firm pressure with the diaphragm of the stethoscope is applied to the chest wall with a patient lying supine

D.               when firm pressure with the diaphragm of the stethoscope is applied to the chest wall at the left lower sternal border.

E.                when firm pressure with the diaphragm of the stethoscope is applied to the chest wall with a patient lying on the right side.

3. The diagnosis of constrictive pericarditis is supported by which of the following findings?

A.               Neck vein distension that increases during inspiration

B.               Exaggerated first and second heart sound (S₁ and S₂)

C.               Unequal diastolic pressure in the four chambers of the heart

D.               A predominance of the lef-sided signs and symptoms over right-sided findings

E.                Inspiratory chest pain

4. The diagnosis of constrictive pericarditis is supported by which of the following findings?

A.               the signs and symptoms of heart failure are out of proportion to the degree of systolic dysfunction or valvular heart disease

B.               Exaggerated first and/or second heart sound (S₁ and S₂)

C.               Unequal diastolic pressure in the four chambers of the heart

D.               A predominance of the lef-sided signs and symptoms over right-sided findings

E.                Inspiratory chest pain

5. Dilated cardiomyopathy often producing symptom of:

A.               congestive heart failure

B.               bradycardia

C.               angina pectoris

D.               paradoxic pulse

E.                elevated serum levels of myocardial enzyme.

6. Which of following electrocardiogram changes acute pericarditis often produces?

A.               widespread elevation of the ST segments with reciprocal depressions only in aVR

B.               Q waves

C.               loss of R-wave amplitude

D.               elevation of the ST segments with reciprocal depression of ST segments 

E.                changes in QRS complexes

7. Which of the following usually causes irreversible dilated cardiomyopathy?

A.               Endocrinopathies (e. g., thyrotoxicosis)

B.               Metabolic disorders (e.g. hypophosphatemia)

C.               Prolonged ethanol abuse

D.               High-dose doxorubicin therapy

E.                Aspirin overdose

8. Examination of the carotid pulse reveals two impulses or peaks during ventricular systole. Which of the following physical findings probably would be associated with this finding?

A.               Diastolic murmur beginning after an opening snap

B.               Decrease in systolic arterial pressure during inspiration

C.               Systolic murmur increasing during the Valsalva maneuver

D.               Right-sided third heart sound

E.                Left-sided third sound

9. Echocardiography can be used successfully to aid in the diagnosis or management of all the following situations EXCEPT

A.     determining left ventricular function after a myocardial infarction

B.      estimating the mitral valve area in a patient with mitral valve stenosis

C.      establishing the presence of an atrial septal defect

D.               excluding the presence of pericarditis

E.                assisting with pericardiocentesis

10. Chest radiograph findings: pear-shaped or water bottle appearance. Choose the single most likely diagnosis from the list of options below.

A.               Mitral stenosis

B.               Constrictive pericarditis

C.               Aortic stenosis

D.               HOCM

E.                Pericardial effusion

 11. A 35-year-old nonsmoking man without significant past medical history presents with chest pain and exertional dyspnea. Review of symptoms is notable for a 1-week history of antecedent flu-like symptoms. Physical examination reveals a JVP of 14 cm H₂0 and rales halfway up the lung fields bilaterally. An S₃ and a lll/VI holosystolic murmur at the apex are noted, as is pitting edema of bilateral lower extremities. ECG reveals diffuse ST-T-wave abnormalities. The initial CPK is 586, with an index of 7%.The most likely diagnosis is:

A.       PE

B.        AMI

C.        Viral pericarditis

D.       Viral myocarditis

E.        НСМ

12. A 36-year-old man presents with intermittent, sharp, mid-sternal chest pain. The pain is somewhat worse with inspiration and associated with mild dyspnea. Several weeks prior, he and his children had “cold” symptoms. What is the most likely diagnosis?

A.       Acute Ml

B.        UA

C.               Stable angina

D.       Spontaneous pneumothorax

E.        Pericarditis

13. A 35-year-old woman with systemic lupus erythematosus complains of sharp left chest pain that is aggravated by breathing. She admits to having felt “under the weather” for the past week with a mild nonproductive cough and rhinorrhea. She has also noted mild dyspnea with exertion. She denies any recent injury or other focal pains. Her lupus has been relatively quiescent and has not required treatment for several years. Physical examination demonstrates a temperature of 38.0°C, BP of 140/82 mm Hg, and HR of 80 bpm. Her JVP is normal and her lungs are clear to auscultation. Cardiac examination reveals normal heart sounds and a faint, coarse murmur that is difficult to characterize. Her ECG is shown widespread elevation of the ST segments. The most likely diagnosis is:

A.       AMI

B.        Acute pericarditis

C.        MS

D.       PE

E.         Pneumonia

14. A 45-year-old woman arrives at your clinic complaining of dyspnea and a dry cough, which she has had for 2 to 3 months. She has been unable to walk more than about 200 ft before developing severe shortness of breath. She denies any fevers but has episodic night sweats. Physical examination demonstrates elevated JVP with prominent waveforms. Notably, there is an increase in the venous distention with inspiration. Her heart sounds are faint, with an early diastolic third sound present. No murmur is heard. The right upper quadrant is tender and the liver pulsatile. ECG reveals sinus tachycardia but is otherwise normal. CXR reveals mild scarring of the right upper lobe of the lungs and a normal-sized cardiac silhouette. The most likely cause of her dyspnea is:

A.       Pericardial tamponade

B.        Pulmonary tuberculosis

C.        Constrictive pericarditis

D.       Acute pericarditis

E.        Severe MS

15. A 25-yr-old woman complains of tiredness and malaise, fever. Her T waves are widespread and deep. Choose the single most likely diagnosis from the list of options below.

A.               Myocardial ischaemia

B.               Left ventricular aneurysm

C.               Aortic stenosis

D.               HOCM

E.                Myocarditis

16.  Following streptococcal sore throat infection, a middle-aged man develops acute chest pain with breathlessness and pallor. His heart rate is rapid and irregular. His cardiac enzymes are normal. There is no evidence of constriction/ right heart failure. Choose the single most likely diagnosis from the list of options below.

A.               Pneumonia

B.               Acute myocarditis

C.               Acute pericarditis

D.               HOCM

E.                Congestive cardiomyopathy

Real-life situations to be solved:

1.     With what disorders have been associated chronic constrictive pericarditis?

2.     A 38-year-old man is seen in the emergency room complaining of severe chest pain. He tends to sit leaning forward. Upon physical examination he is noted to be tachypneic; he has a rapid pulse rate, and on auscultation of the chest his valve sounds appear “distant”. What diagnosis you can suspect? What kind of treatment do you choose?

 

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 cardiomyopathies.

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 – C, 2 – B, 3-A, 4-A, 5-A, 6-A, 7-D, 8-C, 9-D,10-E, 11-D, 12-E, 13- B, 14- C,15-E, 16-B.

Real-life situations. 1. Rheumatoid arthritis and radiotherapy have been rec­ognized for some years as occasional causes of constrictive pericarditis. Recently, cardiac surgery (usually coronary by­pass surgery), including insertion of an epicardial pace­maker, has also been associated with later development of constriction. The lupus-like syndrome caused by procainamide, although frequently including acute pericarditis and pericardial effusion, has not been reported to cause constrictive pericarditis.

 2. All evidences indicate pericarditis with pericardial effusion. Pericardiocentesis via the costoxiphoid approach passes through the rectus sheath and rectus abdominis muscle.

 

 

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 cardiomegaly (cardiomyopathy)

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