STUDY GUIDE
CARDIO-VASCULAR SYSTEM
Y-1 (Spiral-1)
SHIFACOLLEGE OF MEDICINE
CONTENTS
- Introduction to the CVS Module
- Aims
- CVS module theme and their weightage
- Teaching Methodology
- Assessment
- Recommended Textbooks
- Cases Scenarios, objectives and critical questions
INTRODUCTION
On behalf of the module team I welcome you to the Cardio vascular System (CVS) Module!
This module is abeautiful blend of basic and clinical sciences. As you know, CVS is an important system of the body and cardiovascular diseases are among the most common cause of death in both developing and developed countries. Hence, a good understanding of this important system will help you a lot in your future clinical training years. So, be alert and try to learn as much as possible during this period of 6 weeks.
This module has been integrated around cardiovascular system with relevant concepts, principles and skills from anatomy, physiology, biochemistry, embryology, pathophysiology and general medicine. The course has been structured as an integrated study of the human cardiovascular system. It provides instruction into the mechanisms of operation of the human cardiovascular system and the skills needed to evaluate them. Emphasis is placed on the integration of relevant principles with respect to the behavior of normal circulation and its responses to stress and disease.
Cardiovascular module has six themes and cases have been developed to create clinical relevance to whatever is being learned in the sessions.
Your time table will guide you through the module and will also tell you about the learning strategy being used during that very session.
AIMS of cardiovascular Module
To provide a course of integrated learning of normal structure and function of the organs of the cardiovascular system
To provide scientific basis for the understanding of symptomatology of selected cardiovascular disorders as a foundation for future clinical training
Learning outcomes
Our intended learning outcome in terms of knowledge is:
By the end of the module students will be able to:
- Describe the normal structure and function of the different parts of the heart, the aorta and large elastic arteries, arteries, arterioles and capillaries, venules and veins.
- Recognize and identify the changes in structure and/or functioning of the cardiovascular system in the following disease states: valvular heart disease, dysrhythmias, atherosclerosis and ischemic heart disease, congenital heart disease, hypertension and common syndromeslike heart failure, stroke and shock that arise as complications.
In terms of skill our intended outcomes are:
- Identify normal and abnormal findings in the heart and blood vessels on gross, microscopic and radiologic examination
- Interpret circulation physics
- Interpret normal and distinguish abnormal ECGs
- Record blood pressure
- Elicit clinical history in a patient suspected of cardiovascular disease
- Recognize normal and abnormal heart sounds on physical examination
- Perform a focused physical examination of the CVS and recognize abnormalities in common disorders in the disease
- Examine/ palpate all peripheral pulses and recognize alteration in volume, rate and rhythm
- Examine JVP
Our intended outcomes in terms of attitude are to make you aware of:
- Importance of lifestyle modification in the prevention and control of heart diseases
- increasing morbidity and mortality associated with cardiovascular disorders and its psycho-social impact on the individual and family
Teaching Methodology
The content of this module will be delivered by a combination of different teaching strategies. These include small group discussions (SGD), large group interactive sessions (LGIS), demonstrations in dissection hall, lab practical and clinical skill sessions at skill lab. Moreover, you will be given a group project which will be assessed at the end of the block.
Organization & Content Delivery
Organization
The module consists of 6 themes each based on a real life situation. The module will employ different modes of passing instruction. These are briefly described below. Major emphasis will be on discussion, analysis and deductions; all by the students and guided by the faculty.
Content delivery
The various modes of content delivery are briefly described below:
General Information
Entire curriculum will be delivered by clinical case scenarios each covering one theme.
Following tools will be employed to discuss the cases.
a.Small Group Discussion
Main bulk of the course content will be delivered in small group sessions. Each theme has an associated case. The case will be the centre around which learning will take place. Depending on the case you might be required to deduce objectives and learning issues OR only learning issues. Every group will have a facilitator assigned to it. The facilitator will be there to keep you on track giving you maximum liberty to discuss and achieve the objectives as a group. Small groups in some case may be followed by a wrap up session. Rest of the information will be there in the schedule.
b.Large group
Classroom large group instruction will be employed at times sparingly. Attend large group sessions with the following focus
- Identify important points
- Ask questions of points not well understood in the text
- Measure your learning comprehension
c.Videos
Video demonstrations on history taking and clinical examination on diseases like asthma will be shown to give you an idea in to the disease process, testing and practical aspect of communicating with the patients.
d.Hands-on Activities/ Practical
Practical activities, linked with the case, will take place.
e.Lab:
Attend your scheduled lab and take advantage of open times to continue to study.Use your labs to correlate text structures to actual specimens in lab Practice.
f.Self Directed Learning
A few SDLs have been added in between to create an environment for you to search literature as well as to deduce and synthesize information from different sources to meet the learning objectives. It will also help in breaking the monotonous / strenuous schedule.
g. Journal Club Meeting
Few journal club meetings are also scheduled in the module.
Learning strategy
Read the cases and the objectives of the theme which you are suppose to encounter a day before, understand and explain the case to yourself then read the relevant information.
Assessment
In this six weeks duration module, you will have surprise quizzes and intermittent short spotter tests. A full-fledged formative assessment compromising of both MCQs and IPE will be taken at the end of the 4th week. This will give you an idea about the format of the examination that you will go through at the end of the module. Of course, this will be followed by feedback on your performance in the exam.
Comprehensive end of module exam will comprise of:
Marks obtained in the end of module examination and your SGDs evaluation will contribute toward 30% of internal assessment marks for Professional Examination.
Recommended list of Icons
Introduction to case
For Objectives
This Icon will refer to critical questions
This Icon will refer to Lab sessions
This Icon will refer to resource material
This Icon will refer to key words
CVS MODULE THEMES
THEMES:
1- CHEST PAIN 20%
2- BREATHLESNESS WITH SWELLING 30%
3- PALPITATION/ SYNCOPE 15%
4- HYPERTENSION (SILENT KILLER) 20%
5- YOUNG MALE WITH FEVER AND PALPITATION 10%
6- NEWBORN WITH BLUISH DISCOLORATION 05%
Theme 1
Chest Pain
Case history
Patient Profile
Presenting ComplaintM.AAMIR is a 56-year-old male who presents to the Emergency Department with acute onset of chest pain
History of Present Illness:
“I’m having severe chest pain right here,” (the patient indicates his sternal area with a clenched fist). “I was just walking up the stairs to my office when it started. First, it was like a gas pain, but then it got heavier, like a squeezing pain. Now I feel it in the left side of my neck,” (the patient indicates the left anterior neck area), “and it goes down my left arm to my elbow. It won’t let up. It was so bad at first, I had to stop at the top of the stairs and sit down in the hallway. I was so embarrassed! I was sweating and I couldn’t get my breath. I thought, ‘Man, am I out of shape!’ My secretary saw me from her office, and came out to the hallway. She took one look at me, told me to take an aspirin, which I did, and ran back in and called 1122. I was getting kind of lightheaded by the time they finally got there. I felt a little better once they gave me some oxygen. This all happened about a half-hour ago. While moving to the hospital, the Ambulance got stuck in traffic due to VIP movement in front of a pharmacy.”
Past Medical History:The patient denies any significant past illnesses.
Allergies: The patient denies any significant drug or environmental allergies.
Surgical History:The patient has had no surgery.
Hospitalizations:The patient has never been hospitalized.
Personal Health:
Diet:I don’t follow any particular diet.
Exercise: I’m really out of shape. I used to play football, but I don’t think I could run 20 yards now!
Sleep patterns: The patient sleeps approximately six hours nightly.
Caffeine use: I drink about 6 cups of coffee a day.
Nicotine use: Usually about two packs of cigarettes a day. I started when I was 23.
Other substances: Denies the use of non-prescribed controlled substances.
Family Medical History:
“I am the only child. My father died of a heart attack when he was 55 years old. My mother died of stroke at age of 68. She also had high blood pressure and diabetes. I have two children who are married, who live in other cities and have good health.”
Social History and Lifestyle:
I aman attorney by profession and usually works about 50 hours a week. My wife died recently due to CA breast.
Review of Systems
- HEENT: Non-contributory
- Cardiovascular
Other than the chief complaint, the patient denies orthopnea, paroxysmal nocturnal dyspnea, edema, cyanosis, or claudication. He does report dyspnea upon exertion which he attributes to “being out of shape”.
- Respiratory
The patient denies any history of pain, wheezing, chronic cough, hemoptysis, fever, or night sweats.
- GastrointestinalNormal
- Genital/ReproductiveNormal
- UrinaryNormal
- Musculoskeletal.Normal
- EndocrineNormal
- NeuroNormal
- PsychPatient feels depressed after death of his wife
General physical examination
Temperature: 99.8oF
Pulse: 112 bpm with normal peripheral pulses
Respiration: 28 bpm
Blood Pressure: 156/100 mmHg
Weight:185 lbs
Height: 5'9"
General Appearance:56 year old male, oriented to person, place and time, diaphoretic and anxious.
HEENT:
- Head:Normal
- Eyes: Normal
- Ears:Normal
- Nose:Normal
- Throat:Normal
Neck: Thyroid not palpable, trachea central,
Heart: No jugular venous distention, no carotid bruit, no murmurs on auscultation; normal S1 and S2;but tachycardia with regular rhythm.
Lungs: Normal shape chest, equal movements bilaterally, with vesicular breathing, no added sound
Abdomen:flat; non-tender to palpation; no masses; no hepatosplenomegaly, bowel sound present
CNSNo neurological deficit found
Investigations:
Labs:
Cardiac Enzymes:
a) CK: Elevated
b) CK MB: Elevated
c) Troponin I: Elevated
d) AST, LDH: Elevated
Radiology:
Chest X-ray: Normal
Special Investigations:
a) ECG:
ST-elevation in precordial leads V1 to V6
b) Echocardiogram
Regional wall motion abnormality seen
Key words
chest pain,orthopnea, paroxysmal nocturnal dyspnea
Objectives
Theme 1: Chest Pain on Exertion
Describe topographic anatomy of the heart, pericardium,and coronary arteries and of great vessels of mediastinum.
Relate coronary circulation (regulation) in physiological (normal, exercise) and patho-physiological conditions (ischemic heart disease).
Enumerate the salient features of chest pain related to IHD.
Enlist the risk factors for IHD, how they show their effects.
Relate conducting system of the heart with IHD.
Interpret the ECG changes in relation to ischemic area of the heart.
Relate cholesterol and lipoproteins metabolism with ischemia.
Correlate biochemical markers of myocardial ischemia with time duration.
Skills & Attitude:
Demonstrate surface anatomy of the heart, pericardium and great vessels of mediastinum.
Identify the coronary arteries and the areas supplied by them (cadaver/specimen/diagram).
Estimate cholesterol level from given blood sample.
Take history and physical examination of CVS.
Record and interpret ECG (waves, intervals, segments).
Identify the various anatomical structures of CVS visualized by different imaging modalities (X- Ray Chest, Echocardiography).
Perform BLS.
Demonstrate professional attitude when dealing with patients.
Nutritional counseling related to hyperlipidemia.
Counseling for primary & secondary prevention of heart disease
Critical questions
- What are the possible causes of pain in this case?
- Why do you think this is cardiac pain?
- Chest pain with radiation to the neck or arm is a “characteristic” symptom of acute myocardial infarction (AMI) in many patients; explain why the pain can be felt in these distant regions.
- What lab tests will you request for this patient immediately? What additional studies might be appropriate? Justify your answer.
- What is the rationale for measuring cardiac biochemical markers? What is the time course for changes in each cardiac enzyme following acute myocardial infarction (AMI)?
- List cardiac risk factors of this patient. How would you relate dyslipidemia as major risk factor for IHD?
- What are the roles of thrombolytic agents and aspirin in the treatment of coronary artery occlusion? (revisit)
- Which mechanisms cause an acute myocardial infarction (AMI) considering changes in coronary artery?
- What physiological mechanisms lead to tachycardia, tachypnea, and hypertension in this case? What would you have done to help this patient?
- How doeslipid metabolism show effect on the vascular system?
- How will you differentiate normal ECG from an ischemic one?
- How are the changes in the 12-lead ECG associated with infarctions in the following regions: inferior, anteroseptal, anterior, and posterior?
- How would you differentiate between a Q-wave and a non-Q-wave infarction in terms of the ECG appearance and the underlying electrophysiology?
- How would you relate the progression of ECG changes from the first appearance of an acute myocardial infarction (AMI) to several weeks post-AMI to changes in cardiac muscle?
- What is the electrophysiological basis for ST-depression and ST-elevation?
- How do AMI differ between men and women? How might people with diabetes present differently?
Theme 2
Breathlessness with swelling(2)
Case history
Profile: Jamaluddin is a 57-year-old male who presents to the ER.
Presenting Complaint:
Shortness of breath and swollen feet for 4 to 6 weeks.
History of Present Illness: Mr. Jamaluddin has been experiencing progressive shortness of breath with exertion for about the past four to six weeks. At first he tried to ignore the dyspnea, but it has not gone away. He reports that his dyspnea is most pronounced when climbing stairs or walking up hill. The past few days he has also noticed a very rapid and irregular heart rate, as well as some chest pain. Now he describes being short of breath even at rest. He complains of being diaphoretic, and states that his rapid heart rate is making him “very uncomfortable”. He had no history of high blood pressure, heart disease, or “palpitations” prior to the onset of these symptoms several weeks ago.
Past Medical History: hypercholesterolemia; low back pain and cervical dorsal strain/sprain
Injuries:denies any past injuries
Immunizations:yearly immunization for the flu and tetanus is up to date
Medications: denies both prescription and over-the-counter medications
Allergies: denies any significant drug or environmental allergies
Surgical History:has had no surgery
Hospitalizations:has never been hospitalized
Personal History:
Diet:eats a fairly balanced diet
Exercise: follows no particular exercise plan
Sleep patterns: sleeps no more than 5 hours per night
Nicotine use: smokes 20 cigarettes/day
Family Medical History: His mother passed away from a stroke at age 70, and his father died of an abdominal aortic aneurysm at age 75. He denies any other significant family history.
Social History and Lifestyle: He works 70-80 hours per week as a police officer. He eats two meals a day, he tends to catch a snack where he can. The police dept. has a set fitness requirement. Sleep patterns are varied depending on the shift he is working. He does state, however, that he has chronic back pain and has difficulty sleeping at night. He attributes his tendency to fall asleep easily (sometimes at the wheel of his car) to his inability to sleep more than five hours a night starting approximately four months ago. He also denies any drug abuse history. Patient is married. He has no children.
Review of Systems
- Gastrointestinal
The patient denies any history of recurrent abdominal pain, chronic indigestion, heartburn, anorexia, nausea, vomiting, diarrhea, constipation, or hematemesis.
- Urinary
No history of urinary complaints.
- Musculoskeletal
He has back pain as noted and history of cervical strain/sprain. The patient denies any past problems with infections, weakness, or atrophy.
- Endocrine
The patient denies any history of diabetes mellitus, thyroid disorder.