METHODICAL INSTRUCTION FOR STUDENTS OF THE 5 COURSE

foreign students'Faculty

MODULE 2. PRINCIPLES OF INTERNAL MEDICINE

 (cardiology, rheumatology, nephrology, common questions of internal medicine)

Content module 2. Principles of diagnosis, management and prevention of main musculoskeletal disorders

 

 

LESSON ¹ 2 (PRACTICAL – 6 HOURS)

 

Theme13. Rheumatic fever. Infective endocarditis.     

 

Aim - to learn diagnosing and treatment of the rheumatic fever (RF) and infective endocarditis (IE).

Professional orientation of students. Rheumatic fever is common worldwide and responsible for many cases of damaged heart valves. In Western countries, it became fairly rare since the 1960s, probably due to widespread use of antibiotics to treat streptococcus infections. Although the disease seldom occurs, it is serious and has a mortality of 2–5%. Rheumatic fever primarily affects children between ages 5 and 15 years and occurs approximately 20 days after strep throat or scarlet fever. In up to a third of cases, the underlying strep infection may not have caused any symptoms. The rate of development of rheumatic fever in individuals with untreated strep infection is estimated to be 3%. The incidence of recurrence with a subsequent untreated infection is substantially greater (about 50%). The rate of development is far lower in individuals who have received antibiotic treatment. Persons who have suffered a case of rheumatic fever have a tendency to develop flare-ups with repeated strep infections. The recurrence of rheumatic fever is relatively common in the absence of maintenance of low dose antibiotics, especially during the first three to five years after the first episode. Heart complications may be long-term and severe, particularly if valves are involved.

Infective endocarditis (IE) is an infection of the endocardial surface of the heart. The intracardiac effects of this infection include severe valvular insufficiency, which may lead to intractable congestive heart failure and myocardial abscesses. IE also produces a wide variety of systemic signs and symptoms through several mechanisms, including both sterile and infected emboli and various immunological phenomena. Endocarditis has evolved into several variations, keeping it near the top of the list of diseases that must not be misdiagnosed or overlooked. The incidence of IE is approximately 2-4 cases per 100,000 persons per year. This rate has not changed in the past 50 years.

 

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 pathogenesis of RF.

2.     Major and minor criterion for RF (WHO, 1987; NYHA, 1992).

3.     Classification, structure of clinical diagnosis of the patient with RF.

4.     Differential diagnostics of RF depending on leading syndromes (carditis, arthritis).

5.     Treatment of RF.

6.     Primary and secondary prophylaxis of the RF.

7.     Etiology and pathogenesis of IE

8.     Risk factors of the IE.

9.     Pathogenesis of IE.

10.   Modern imagination about problems of relationship of RF and IE.

11. Pathomorphology of IE (involvement of heart valves, frequency of their damage, causes for vasculitis; spleen, kidneys, lung, liver, CNS involvement).

12. Classification of IE.

13. Clinical features of IE.

14. Laboratory changes in IE.

15. EchoC features in IE.

16. Diagnostic criteria for IE.

17. Differential diagnosis of IE.

18. Course of IE.

19. Complications and prognosis of IE.

20. Principles of the treatment of the IE.

21. Principles of the treatment of complications of the IE.

22. Indications to the surgical treatment of the IE.

23. Common principles of the IE prophylaxis. Schemes of the IE prophylaxis by antibiotics in the different causes of medical manipulations.

Test evaluation and situational tasks.

10 multiple choice tests

Multiple Choice Questions

Choose the correct answer/statement

1.     Echocardiographic findings for infective endocarditis are all of the following EXCEPT:

A.   New vulvar stenosis

B.   Mobile echo dense masses attached to valve leaflets or endocardium

C.   Per annular abscesses

D.   New dehiscence of a prosthetic valve

E.    New vulvar regurgitation

2.     A 14-yr-old boy has had a pyrexia, rash, raised ESR, 2 weeks after pharyngitis. Subcutaneous nodules and a generalized rash is noted on the trunk. Choose the single most likely diagnosis from the list of options below.

A.   Maculopapular rash

B.   Erythema multiforme

C.   Erythema marginatum

D.   Lichen planus

E.    Erythema nodosum

3.     A 15-year-old boy is brought by his mother for evaluation of fever. All of the following would suggest the diagnosis of acute rheumatic fever EXCEPT:

A.   shortened P-Q interval on ECG.

B.   rapid, involuntary, purposeless movements

C.   migratory polyarthritis

D.   subcutaneous nodules

E.    a rash on the trunk and proximal extremities

4.     A 15-yr-old boy presents with polyarthritis and abdominal pain. He had a sore throat a week ago. On examination he is noted to have an early blowing diastolic murmur at the left sternal edge. Choose the single most likely diagnosis from the list of options below.

A.   Acute rheumatic fever

B.   Congestive heart failure

C.   Aortic stenosis

D.   SLE

E.    Mitral stenosis

5.     A 28-yr-old woman with a heart condition has a rash on her lower arms. It is pink or red and ring like. It moves up and down her arms and she can not get rid of it. Choose the single most likely diagnosis from the list of options below.

A.   Maculopapular rash

B.   Erythema marginatum

C.   Erythema multiforme

D.   Lichen planus

E.    Erythema nodosum

6.     A 15-year-old girl is evaluated for a fever and joint pains. Three weeks earlier, she had a sore throat that resolved without treatment. Four days ago, she developed pain and swelling of the right ankle and the right elbow. Today she complains of pain and swelling of the left knee. Physical examination reveals a temperature of 101°F and an HR of 110. Laboratory evaluation demonstrates an elevated ant streptococcal antibody. In regard to this patient, which of the following statements is true?

A.   She should receive benzathine PCN every 3 weeks until she is 25 years old.

B.   Blood cultures are likely to be positive for group A streptococci.

C.   Cardiac examination is also likely to disclose an OS and a low-pitched middiastolic murmur at the cardiac apex.

D.   Acute antibiotic treatment is not required, as the patient's sore throat has resolved.

E.    She may have residual deformity of her left knee.

7.     A 40-yr-old drug addict::A 40-yr-old drug addict is noted to have a PSM at the bottom of the sternum. Giant 'cv' waves are present in the JVP. Choose the single most likely diagnosis from the list of options below.

A.   Rheumatic MR

B.   Congenital AS

C.   Atrial myxoma

D.   Congenital PS

8.     A 52-year-old man residing with his parents on a military base presents with a fever of 38.6 ° C and complains of lower back, knee, and wrist pain. The arthritis is not localized to any one joint. He gives a history of a severe sore throat several weeks earlier. Laboratory investigation includes negative blood cultures, negative throat cultures, normal CBC, and erythrocyte sedimentation rate (ESR) of 100. An antistreptolysin- O (ASO) titer is elevated. This point, appropriate therapy would consist of

A.   parenteral penicillin and aspirin

B.   supportive care alone

C.   parenteral penicillin

D.   parenteral penicillin and glucocorticoids

E.    parenteral penicillin, aspirin, and diazepam

9.     A 40-yr-old woman presents with malaise and low-grade fever for 2 weeks. She recently had treatment for a dental abscess. On examination she has splinter haemorrhages and an early diastolic murmur. Choose the single most likely treatment from the list of options below.

A.   2 or more antibiotics together

B.   Amoxycillin

C.   Ciprofloxacin

D.   Cefotaxime

E.    Co-amoxiclav

10.       A 43-yr-old woman presents with fever and weight loss. She is pale and her spleen is enlarged. Her fingers are mildly clubbed with painful lesions on the pulps. She is breathless. Choose the single most likely diagnosis from the list of options below.

A.   Infective endocarditis

B.   Left atrial myxomaq

C.   Pericarditis

D.   SLE

E.    Bacteraemia

Real-life situations to be solved:

2 real-life situation to be solved

2. A 34-year-old man comes into the emergency room with the recent onset of fever (38-39 C), dyspnea, palpitation. A high-pitched, diastolic murmur, heard best in the third intercostal space along the left sternal border. It is suspected infective endocarditis. What sing would be found echocardiography?

3. Patient M., 14 years, complains on feeling of reinforced and speed-up palpitation, unsignificant dyspnea at loading. She ties worsening of condition with carried pharyngitis two weeks ago. It's known from anamnesis , that in 6-th annual age she treated on the subject of chorea minor. Objectively: body temperature is 37,5°C, insignificant hyperemia of pharynx's back wall, pallor of dermal covershyperhydrosis. Left heart boundary during the percussion is in V i/c on 1 sm outside from l.medioclavicularis sin. Heart rate is 100 / min. Action of heart is rhythmic, tachycardia, relaxation of 1 tone over top, short changeable systolic murmur.

General blood analysis : L -12000; ESR is 20 mm/hour. Biochemical blood analysis: A-globulins are 12 %, the gamma-globulins are 25 %; syalic acids - 220 Units; seromucoid - 250 Units; CRP - (++); ASL-0 - 1: 600. On ECG- p-q = 0,22 s. What is the preliminary diagnosis?

 

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.     Etiology of RF.

2.     Pathomorphology and pathogenesis of RF.

3.     Major and minor criteria for RF.

4.     Clinical classification of RF.

5.     Principles and methods of RF treatment and prophylaxis.

6.     Modern imagination about problems of relationship of RF.

7.     Etiology and risk factors of IE.

8.     Pathogenesis and  pathomorphology of  IE.

9.     Clinical features of IE. Complications and prognosis of IE.

10. Principles treatment of IE.

11. Main schemes of the antibiotics treatment according to the IE etiology. 6. Indications to the surgical treatment of the IE.

12. Common principles of the IE prophylaxis. 

 

Students should be able to:

1.     History taking and physical examination of the patients with RF.

2.     Call syndromes in RF and making differential diagnosis of RF.

3.     Interpret data of laboratory and instrumental methods of examination

4.     Make full diagnosis of RF.

5.     Make plan of examination of patient with RF.

6.     Prescribe the treatment of the RF

7.     Evaluate prognosis for patient with RF.

8.     History taking and physical examination of the patients with  IE.

9.     Call syndromes in RF and making differential diagnosis of IE.

10. Make full diagnosis of IE.

11. Make plan of examination of patient with IE.

12. Evaluate prognosis for patient with IE.

13. Prescribe the treatment of the IE.

14. Evaluate dates of additional investigations in the patient with IE.

 

Correct answers of test evaluations and situational tasks:

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

Real-life situations.

The correct answer is

1. Vegetations are recognized substantially more frequently in two-dimensional echocardiography - show valvular destruction and vegetations.

2. Reccurent rheumatic fever, Active phase, act.: degree II.

References.

À- 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:

  1. http://intranet.tdmu.edu.ua: Rheumatic fever.   Infective endocarditis
  2. www.eular.org
  3. www.rheumatology.org
  4. http://emedicine.medscape.com/
  5. http://meded.ucsd.edu/clinicalmed/introduction.htm

 

 

B- Additional:

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. Oxford Handbook of Cardiology (2nd ed.) / by Ramrakha P., Hill J., eds. – OxfordUniversity Press, 2012. – 851 p.

 

 

Methodical instruction was been worked out by: Prof. S.I.Smiyan28” August, 2013.Minute ¹ 1

Methodical instruction was adopted and reviewed 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