January 3-7, 2005 Cardiovascular II
GOALS AND INSTRUCTIONAL OBJECTIVES GOALS: By the end of the week, the second quarter student will have an in-depth understanding of the diagnoses listed under Primary Diagnoses and Secondary Common Diagnoses. The second quarter student will accurately perform an appropriate history and physical exam on a patient or patient model presenting with one of the cardiovascular diagnoses listed under Primary Diagnoses, Secondary Diagnoses, and Tertiary Diagnoses when seen at the student’s clinical site or during a practicum exam. The second quarter student will explain the pathophysiological changes that are associated with the following conditions: Premature atrial contractions (PAC’s) Supraventricular tachycardia (SVT) Paroxysmal atrial tachycardia (PAT) Atrial fibrillation (AF) Atrial flutter First degree heart block Second degree heart block Third degree heart block Stokes-Adams attack
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Premature ventricular contractions (PVC’s) Ventricular tachycardia (V-tach) Ventricular fibrillation (V-fib) Acute rheumatic hear disease Myocardial infarction (MI) / Acute coronary syndrome Pericarditis - post MI Cardiac arrest
The student will also be able to describe how these changes may present in the patient, the content of an appropriate history, the expected findings in a physical exam, and an appropriate treatment plan or work-up. OBJECTIVES The second quarter student will complete the following: !
Accurately explain the epidemiology of primary and secondary common diagnoses.
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Name the (S) chief or common presenting complaint and relevant descriptors of the primary, secondary common and uncommon and tertiary diagnoses.
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Accurately distinguish between (O) Objective negative and positive findings while performing a routine or specialty physical exam technique when evaluating for, or in the presence of, the conditions listed for each primary, secondary common and uncommon, and tiertiary diagnosis.
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Formulate a (A) Diagnosis and list relevant differential diagnoses from information gathered through history taking, physical exam, and diagnostic test results provided via case studies or reports or collected in the clinical setting.
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Identify risks associated with specific missed diagnosis
Identify on written exam or in case presentation of a patient model or clinic patient, a (P) Plan outlining the appropriate medication, non-medicinal treatment, patient education and follow-up evaluation for primary and secondary common diagnoses.
(D) = definition only CARDIOVASCULAR: ANATOMY AND PHYSIOLOGY The second quarter student will recognize and explain the anatomy, physiology, and common pathophysiology in sufficient depth for clinical application related to the following Cardiovascular, Hematological, and Ophthalmological components. To meet this objective the student will utilize textbooks, models, electronic,computer or web-based programs, radiographic resources, and lectures according to the standards identified in the Primary Care Associate Program required texts (see booklist in Student Manual). The second quarter student will be responsible for basic anatomic knowledge of the cardiovascular system with emphasis on clinically relevant areas. The second quarter student will utilize required texts and lecture material to develop an understanding of the clinically important concepts of the following: ! ! ! !
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Chambers and vessels in the circulatory flow route, including systemic, pulmonary, and portal pathways. The heart valves and their positions in systole and diastole. Surface projections of the heart, position in the chest, and the four auscultatory positions. The coronary arteries: right coronary, left main and its two branches, the left anterior descending and circumflex; origin and general distribution. Location and distribution of main arteries: aorta (thoracic and abdominal), carotids.
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Location of important veins: inferior vena cava (IVC), external and internal jugular. State the origin and termination of the portal system, and why this is significant in cardiac disease. Conduction system: sinoatrial node (SA), arterioventricular node (AV), HIS bundle. Nervous control of heart: sympathetic, vagus.
Basic cardiovascular physiology will be reviewed to the extent necessary to understand fundamental signs, symptoms, and diseases. ! ! ! !
Intrinsic rhythmicity of conduction system, and delay points: reflection on EKG. Natural homeostatic feedback loops influencing heart rate; blood pressure; (Starling's Law of the Heart). Normal ranges of pulse and blood pressure through age groups and exertion. Diminished capacity with aging.
DISEASE Primary Diagnoses: The second quarter student will state the epidemiology, basic pathophysiology, etiological agents, and/or risk factors, preventive measures, signs and symptoms, differential diagnoses, investigative measures, management and patient education for the following diagnoses: ! !
Health maintenance: CV promotion and screening Conduction disorders • Chronic atrial fibrillation • Management of chronic stable arrhythmias
Secondary Diagnoses (Common): The second quarter student will state the epidemiology, basic pathophysiology, etiological agents, and/or risk factors, preventive measures,
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signs and symptoms, differential diagnoses, investigative measures, general principles of management and patient education for the following diagnoses. Physician consultation is expected. !
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Ischenic heart disease • New onset angina • Coronary artery disease Conduction disorder • New onset premature atrial contractions (PAC’s) • New onset atrial fibrillation (AF) • Anticoagulant therapy in chronic atrial fibrillation (CAF)
Secondary Diagnoses (Uncommon): The second quarter student will state the epidemiology, basic pathophysiology, signs and symptoms of the following diseases. !
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Cardiomyopathy • Dilated • Hypertrophic • Restrictive Conduction disorders • Supraventricular tachycardia (SVT) • New onset premature ventricular contractions (PVC’s) Other forms of heart disease • Rheumatic heart disease, acute • Pericarditis - post MI
Tertiary Problems: Problems Requiring Emergency Management or Hospitalization: The second quarter student will be able to recognize these disorders and initiate treatment. As well, they should be able to describe and identify the basic pathophysiology, risk factors, preventive measures, patient education and referral sources as appropriate:
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Conduction disorder • Arrhythmias: PAT, uncompromised Atrial Fibrillation/Flutter with a rapid ventricular rate; Ventricular Fibrillation, Ventricular Tachycardia • Stokes-Adams attacks • Elevated INR levels in the anticoagulated patient Ischemic heart disease • Acute chest pain • Myocardial infarction Vascular disease • Arterial embolism / thrombosis
CLINICAL PROBLEMS For each problem the second quarter student will be able to perform a focused history and physical, generate a differential diagnosis, and order appropriate diagnostic tests. They will be able to present the problem orally, do a write-up in SOAP format, and manage the diagnoses in Primary and Secondary Common Diagnoses. ! ! ! ! ! !
Chest pain. Palpitations. Fatigue. Syncope. Cyanosis. Increased bruising, bleeding gums, hematuria, hematochezia, melena
OBJECTIVE In addition to the basic exam, the second quarter student will be able to perform the following physical exam maneuvers: ! ! !
Fundoscopy. Pulse (apical and radial) Cardiac: • Inspection - point of maximum impulse (PMI),
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Palpation - for heaves, lift, PMI, tenderness, thrill, Auscultation < To recognize S 1, S 2, gallops (S 3, S 4), friction rubs, clicks Correctly perform an electrocardiogram.
Recognize the listed abnormalities: ! ! !
Cyanosis Bruising Pallor
PLAN Evaluation studies: State the indications for the following tests. Explain the significance of a normal vs abnormal result in relation to the diagnoses listed under Primary, Secondary Common and Uncommon, and Tertiary Diagnoses, and describe the general cost effectiveness of the following tests: !
Lab • Electrolytes - Na, K, Cl, HCO 3 • Cardiac enzymes – CPK isoenzymes, SGOT, LDH (state which rises late) Troponin T & I • Urinalysis • BUN, creatinine • cholesterols and triglycerides • PT/INR • PTT
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Radiology • Chest X-ray • Coronary arteriography • Echocardiogram
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Other studies • EKG < Rate, rhythm, P-wave, P-R interval, QRS complex < Normal sinus, sinus bradycardia and tachycardia.
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Atrial fibrillation and flutter. Atrial and ventricular premature beats. Ventricular fibrillation and tachycardia. Asystole. Axis. Ventricular hypertrophy. Ischemia. Acute myocardial infarction.
Exercise EKG for evaluation of CAD Holter monitor for evaluation of Arrhythmia, CAD Cardiac catheterization for evaluation of CAD Thallium scan for evaluation of Cardiac function
! Treatment The first quarter student will identify the indications, contraindications, side effects and describe the general cost effectiveness of the following treatment plans: •
Medications (In addition to the items listed below, read the appropriate sections in the Pharmacology Syllabus.) Medication Use
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