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.
·
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.
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
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-
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 covers, hyperhydrosis. 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.
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:
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.
Methodical instruction was been worked out by:
Prof. S.I.Smiyan “
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