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 № 5 (PRACTICAL - 6 HOURS)
Theme
5: Acquired valvular heart diseases
Aim: to develop skills and to acquire experience relevant
to management of patients with acquired valvular heart disease.
Professional
Motivation: 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.
·
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. 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%,
C. NYHA functional class II, EF 50%
D. NYHA functional class II, EF 70%, LV end systolic diameter
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
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
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.
References.
A - Basic:
2.
Harrison's
Principles of Internal Medicine / –
3.
Kumar
and Clark's Clinical Medicine (8th Revised edition) (With studenconsult Online Access)
/ –
4. Web -sites:
www.tdmu.edu.ua:Acquired Valvular Heart Disease
B - Additional:
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. –
4. Valvular Heart Disease / B. W. Andrus. –
5. Valvular Heart Disease in
Clinical Practice / . –
6. Clinical Echocardiography (2 revised edition) / . M. Y.
Henein. -
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: 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