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 ¹ 4 (PRACTICAL - 6
HOURS)
Theme 4:
Atherosclerosis. Chronic stable
angina
Aim: to develop skills and to acquire experience relevant
to management of patients with atherosclerosis
and chronic coronary heart disease.
Professional Motivation: Cardiovascular disease (CVD) is
the leading cause of morbidity and mortality in the industrialized world,
accounting for approximately 40 % of all deaths. Given the enormous burden of
CVD, the high prevalence of lipid disorders, and effective evidence-based
treatment strategies, recognition of and management of lipid disorders is an
essential component of both primary and secondary prevention of CVD. The
presence of symptomatic coronary heart disease (CHD) affects quality of life
negatively. It imparts significant morbidity and mortality, with a 3,5 % annual
risk of myocardial infarction and 30 % 10-year mortality risk, roughly twice
that of age-matched controls. Pharmacologic and revascularization therapies
aimed at reducing symptoms and improving survival in this broad population of
patients are a fundamental aspect of modern clinical cardiology.
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.
·
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
Multiple
Choice Questions
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:
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
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
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 normal 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. 3 - D.
References.
A - Main:
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. Harrison’s principles of internal
medicine (18th 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: Atherosclerosis
b) http://emedicine.medscape.com/
c) http://meded.ucsd.edu/clinicalmed/introduction.htm
B - Optional:
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., 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 (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: assos. prof.
R.R. Komorovsky, MD
Methodical
instruction was discussed and adopted at the Department sitting 15.06.2009,
Minute ¹ 2
Methodical instruction was adopted
and reviewed at the
Department sitting 29.06.2010, Minute
¹ 19
Methodical instruction was adopted
and reviewed at the
Department sitting 16.06.2011, Minute
¹ 13
Methodical instruction was adopted
and reviewed at the
Department sitting 12.06.2012, Minute
¹ 12
Methodical
instruction was adopted and reviewed at the Department sitting 25.06.2013, Minute ¹ 17