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 ¹ 10 (PRACTICAL - 6 HOURS)

Theme 10: Arrhythmias.

 

Aim: to develop skills and to acquire experience relevant to management of patients with arrhythmias and heart blocks.

Professional Motivation:

Arrhythmias is a common problem in hospitalized patients, with a prevalence rate of about 1%. It is frequently not adequately diagnosed. Although it is the immediate cause of death in about 10% of patients who die in U.S.

 

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 Question. Choose the correct answer/statement

 

1.     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

 

2.     The following cardiovascular malformations are all associated with congenital rubella EXCEPT:

 

A.   PDA

B.    PA stenosis

C.    Ebstein's anomaly

D.   Tetralogy of Fallot

E.    Coarctation of the aorta

 

 

3.     Which of the following syndromes is associated with pumonary arterio-venous fistula?

 

A.   Williams syndrome

B.    Weber-Osler-Rendu syndrome

C.    Bland-Garland-White syndrome

D.   Kartagener's syndrome

E.    Crouzon's syndrome

 

4.     Congenital MR is commonly encountered in all of the following conditions EXCEPT:

 

A.   Cor triatriatum

B.    Ostium primum ASD

C.    Coarctation of the aorta

D.   Congenitally corrected TGA

E.    Subaortic stenosis

 

5.     In which of the following cases is surgical correction recommended?

 

A.   Asymptomatic small VSD to decrease risk of endocarditis

B.    PDA with severe pulmonary hypertension

C.    Asymptomatic subaortic stenosis with severe aortic valve insufficiency

D.   Coarctation of the aorta with a transcoarctation gradient of 20 mmHg

E.    Small ASD to prevent paradoxical embolization

 

6.     Which congenital disorder corresponds with the following chest radiography findings: prominent central PAs (possible calcifications) and peripheral PA prunning?

A.   Eisenmenger's syndrome

B.    Coarctation of the aorta

C.    PDA

D.   Ebstein's anomaly

E.    Tetralogy of Fallot

7.     Which congenital disorder corresponds with the following chest radiography findings: right aortic arch, RV enlargement, and a "boot-shaped" heart?

 

A.   Eisenmenger's syndrome

B.    Coarctation of the aorta

C.    PDA

D.   Ebstein's anomaly

E.    Tetralogy of Fallot

 

8.     Which congenital disorder corresponds 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

9.     Which congenital disorder corresponds with the following chest radiography findings: posterior rib notching and a "reverse E" or "3" sign

 

A.               Eisenmenger's syndrome

B.               Coarctation of the aorta

C.               PDA

D.               Ebstein's anomaly

E.                Tetralogy of Fallot

 

10.           Which congenital disorder corresponds with the following chest radiography findings: pulmonary plethora, prominent ascending aorta, proximal PA dilatation, and opacity at the confluence of the aortic knob and descending aorta

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. An 80-year-old with a past history of MI is found to have left bundle branch block on ECG. She is asymptomatic, with BP 130/80 mmHg, lungs clear to auscultation, and no leg edema. On cardiac auscultation, which of the following is the most likely finding?

 

A. Fixed (wide) split S2

B. Paradoxical (reversed) split S2

C. S3

D. S4

E. Opening snap

 

2. A 62-year-old male with underlying COPD develops a viral upper respiratory tract infection and begins taking a decongestant. Shortle thereafter he experiences palpitations and presents to the ER, where the following strip is obtained. The rhythm demonstrates which of the following?

 

A. Normal sinus rhythm

B. Junctional rhythm

C. Atrial flutter with 4:1 atrioventricular block

D. Paroxysmal atrial tachycardia with 2:1 atrioventricular block

E. Complete heart block

 

3. A 17-year-old girl is evaluated for a routine precollege physical examination. She is not athletic but has no effort intolerance to usual activities. She has no history of heart disease but has been told that her heart rate is slow.
On physical examination, blood pressure is 102/60 mm Hg and heart rate is 40/min. Cardiac examination shows S1 that varies in intensity and is occasionally booming. The rest of the findings are normal. A rhythm strip from her electrocardiogram is shown.

What is the most likely cause of bradycardia in this patient?


A. Excess vagal tone
B. Autonomic dysfunction
C. Congenital complete heart block
D. Use of the drug “ecstasy”
E. Sick sinus syndrome


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)

 

Student should know:

1. Cardiovascular anatomy.

2.Cardiovascular physiology and pathology.

3. History taking, inspection and physical examination of cardiovascular patients.

4. Principles of laboratory and instrumental evaluation of cardiovascular patients.

 Student should be able to:                  

1. Perform a clinical exam of the 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.

8. Establish indications for electrophysiological study and invasive management of arrhythmias and heart blocks.

 

Correct answers of test evaluations and situational tasks:

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

Real-life situations. 1. E 2. C 3. C.

 

References.

A - Basic:

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: Arrhythmias

b)     http://emedicine.medscape.com/

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

 

B - Additional:

1.      Lawrence M. Tierney, Jr. et al: Current Medical Diagnosis and treatment 2000, Lange Medical Books, McGraw-Hill, Health Professions Division, 2000.

2. 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.

3. Braunwald’s Heart Disease: review and assessment (9th ed.) / Lilly L.S., editor. – Saunders, 2012. – 320 p.

4. Cardiology Intensive Board Review. Question Book (2nd ed.) / by Cho L., Griffin B.P., Topol E.J., eds. – Lippincott Williams & Wilkins, 2009. – 385 p.

5. Cleveland Clinic Cardiology Board Review / Griffin B.P., Kapadia S.R., Rimmerman C.M., eds. – Lippincott Williams & Wilkins, 2012. – 952 p.

6. Hurst’s the Heart (13th ed.) / by Fuster V., Walsh R.A., Harrington R., eds. – McGraw-Hill, 2010. – 2500 p.

7. 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