Student Module for Cardiovascular

Student’s work book

MODULE

CARDIOVASCULAR

Academic year 2011-2012

CARDIOVASCULAR SYSTEMMEDICAL FACULTY

HASANUDDIN UNIVERSITYMAKASSAR

2011

Cardiovascular system : 2

INTRODUCTIONThe best medical care for patients with cardiovascular disease primarily depends upon the bestdiagnostic foundation provided by careful and in-depth history taking, and physical examination.Many physicians are familiar with the so called “five fingers approach” to cardiovasculardiagnosis, popularized by Harvey. This consists of:

1. History2. Physical examination3. Electrocardiogram4. Chest X-ray5. Various other laboratory tests

Although some cardiovascular disorders can be diagnosed with a single modality, a fullunderstanding of the patient’s problem usually requires the use information from several sources.The history and physical examination may overlap each other in certain areas, but importantdiagnostic information is often obtained while taking the history alone. When any abnormalphysical finding is demonstrated, of course, additional history pertinent to the finding will betaken in order to confirm the clinical diagnosis. Special diagnostic procedures, such as cardiaccatheterization, echocardiography, nuclear scanning, treadmill test, ambulatory (Holter monitor)electrocardiography, etc, are often necessary for accurate diagnosis and proper treatment.

This Dyspnoea module consists of three units. Each unit come with scenarios, studyingstrategies, tasks, tutor guidance, some alternative questions and answers and some references.

The scenarios function as learning stimulus during the first session of group discussion,with or without tutors. Students are expected to generate a number of questions with alternativeanswers and its references. Unsolved problems are assigned as home works to be discussed onthe second session in another day.

Before using this book, students and tutors should have read the learning strategies, theseven-jump method, learning objectives (GIOs and SIOs), so that the discussion will not divergeelsewhere, and minimal competence required in the section will be achieved in an efficient time.During this period of tutorial, the role of tutor to converge the discussion is very important.

Expert lectures will also be given if they are needed by experts in the field, and directexpert consultations may be carried out after an appointment.


LEARNING STRATEGIES1. Group discussion without tutor, free brainstorming between students.2. Group discussion guided by tutor to point the alternative question to the specific problem.3. Consultation to the experts to acquire more in depth comprehension.4. Specific lectures in the classroom.5. Individual active learning in the library and electronic media.6. Practical works in the skills laboratory.7. Laboratory practices.

THE SEVEN-JUMP METHOD1. Clarify terms and concepts in the problem unknown to you.2. Define the problem : list the phenomena to be explained.3. Explain the problem : try to produce as many different explanations for the phenomena.4. Arrange the explanations proposed: try to produce a coherent description of the process

that, according to what you think of. Use prior knowledge and common sense.5. Formulate learning goals/ learning objectives.6. Attempt to fill the gaps in your knowledge through invidual study.7. Share your findings with your group and try to integrate the knowledge acquired into a

comprehensive explanation for the phenomena.

STUDENT TASK1. After reading the scenario carefully, students discuss about it in a discussion group of 12-15

persons. This discussion is conducted by a chairman and a writer from the students group.The chairman and the writer should be changed each discussion time. Group discussion canbe conducted by a tutor or autonomously.

2. Apply individual study activity in the library using work books, magazines, slides, tapes orvideos, internet etc., to search for addition information.

3. Apply discussion group without tutor, do discussion between group to analysis or tosynthesis information in solving problem.

4. Apply consultation with source speaker that is expert in the problem to gain morecomprehension about the problem (ask expert).

5. Pursue specific lecture (expert lecture) in the class for problems that are not well understoodor haven’t found the answers.

6. Apply practicum in laboratories.


Addition Explanation:

If there is still information that is needed to reach the end conclusion from group report,then process 6 can be repeated, and then do step 7 again.

Both steps above can be done repeatedly in the tutorial or outside the tutorial and in everyend of the discussion determine the goal of the next study. After the information is enough thenthe report is due in the end of discussion, usually done in panel discussion where all the expertssit together to give explanation about things that are not clear yet.

PROBLEM SOLVING PROCESS

In group discussion using discussion method, students are expected to be able to solve theproblem in the scenario, using the 7 steps of problem solving below:1. Clarify the unclear terminology in the scenario above, and then determine the key

word/sentence of the scenario above.2. Identify the basic problem of scenario by making several important questions.3. Analysis and synthesis the gathered information by answering questions that had been made

above.4. Classify the answers of the questions above.5. Determine the study objective that want to be achieve by students group according to the

cases above.Steps 1 to 5 are done in the self-discussion and the first discussion with tutor.

6. Students obtain more information about the cases above outside the group.7. Students report the discussion result and the synthesis of information that is just discovered.

Step 7 is done in the discussion group with tutor.

ACTIVITY SCHEDULE

1. The first meeting in the big class with one direction of face to face by coordinator systemor MEU staff. This meeting explains about the module and the way of modulecompletion, and divides a discussion group. In this meeting the students is given ModuleWork Book.

2. The second meeting is tutorial discussion; it’s conducted by students who are elected tobe the group chairman and writer, and also facilitate by two tutors. The objective is toaccomplish step 1 to 5 in problem solving process (brain storming) and divide tasksbetween discussion group members.


3. The third meeting is tutorial discussion; it’s conducted by students who are elected to bethe group chairman and writer, and also facilitate by two tutors. The objective is to reportthe self discussion result, do analysis and synthesis from the new information. Theprocess can be done again from step 5 of the problem solving problem.

4. Students study autonomously, alone or group. The objective is to search for newinformation that is needed.

5. The fourth meeting is tutorial discussion. The objective is to report the last discussionresult and synthesis information that is just obtained. If new information is still needed,continue it again like no. 2 and no. 3 above.

6. The last meeting is due in the big class in a panel discussion form to report each of thegroup discussion result and ask about things that haven’t been answered to the expert(expert meeting).

TIME TABLEMEETINGS

I II III IV V VI VII1st meeting Independent Tutorial I Indepen- Lecture Tutorial II Last meeting(overview meeting Gathering dent Consultat- (Report and (Report)

explanation) (BrainStroming)

informationAnalyse &sintethyse

PracticalCSL

ion discussion)

REFERENCESA. Cardiovascular lectures from different field of studies.B. Textbooks/Journals that are related to cardiovascular study.

1. Levick JR. (2003). An Introduction to Cardiovascular Physiology. 4th edit.ArnoldLondon.

2. Bickley LS (2003). Bate’s Guide to Physical Examination and History Taking. 8th edit.Lippicott Williams & Wilkins, Philadelphia.

3. Braunwald E, Zipes DP, Libby P. (2001). Heart Disease A Textbook ofCardiovascular Medicine. 6th edit. W.B. Saunders Coy, Philadelphia.

4. Fuster V, Alexander RW, O’Rourke RA. (2001). Hurst’s The Heart 10th edit.International Edit. Mc Graw-Hill, New York

5. Chung EK. (1983). Quick Reference to Cardiovascular Diseases. 2nd

edit.J.B.Lippincot Coy, Philadelphia.6. Crawford MH (2003). Current Diagnosis &Treatment in Cardiology. 2nd edit Lange Med

Books/McGraw-Hill, New York.7. Coats A, Cleland JGF. (1997). Controversies in the Management of Heart Failure. 1st

edit. Churchill Livingstone, Edinburg.

Cardiovascular system

8. Branch WT Jr, Alexander RW, Schlant RC, Hurst JW.(2000). Cardiology inPrimary Care. Intern. Edit. McGraw-Hill, New York.

9. Braunwald E, GoldmanL. (2003). Primary Cardiology 2nd Edit. Saunders,Philadelphia.

10. Hardjoeno H. dkk (2003) : Interpretasi Hasil Tes Laboratorium Diagnostik.LEPHAS.Makassar.

11. Khan MG. (2003). Cardiac Drug Therapy. 6th edit.Saunders, Philadelphia.

LECTURERS

NO. TELPNO NAMA ALAMAT

Rumah/flexi HP

1 dr. Ali Aspar Mappahya,SpPD,SpJP Jl. Sunu Komp Unhas A 7 453 453 0811416392

2 dr. Harfiah Djayalangkara Jl Maccini Sawah 442 818 0811443235

3 dr. Arthur Koeswandi Jl. Pongtiku 081342759294

4 dr. Irawan Yusuf, PhD Komp. Dosen Antang 5058294 08152529560

5 dr. Agnes Kwenang Jl. Sunu Komp Unhas DXl 434 639 081342347525

6 dr. Baedah Madjid, SpMK Jl. Sunu Komp Unhas AX 13 5702491 0811444326

7 dr. Gatot L Lawrence, SpPA Jl. HOS cokroaminoto 29 B 312 365 0816255306

8 Prof.dr.Peter Kabo, Ph.D, SpFK Jl. Muchtar Lutfi 21 320 348 0816275383

9 Prof.Dr.dr.Boy Pellupessy, SpA (K) Jl. Pengayoman

11 dr. Pendrik, SpPD

10 Prof.Dr.dr.Syakib Bakiri, SpPD 0816250620

12 dr. Ruland DN Pakasi, SpPK (K) Komp. Kes. Banta-bantaeng 872 006 0816255713

13 dr. Arief Gella, SpRad BTN Hamzy 585 235 04115078062

14

15

16

dr. Satriono, SpA(K)

dr. Nur Alim, SpB dr.

Tahir Abdullah

Jl. Sunu Komp Unhas AX 13

449 566

08124124652


MODULE 1 DYSPNOEA

LEARNING OBJECTIVES

General Instructional Objectives (GIOs) :

After studying this module, the students will comprehend the basic concepts of dyspnoea-relateddiseases and should be able to diagnose some cardiovascular diseases relating to this symptom.

SCENARIO 1A 60 year old woman complain of feeling easily get tired and hard to breath when she is doing anactivity. She can not do chores longer without taking a rest because of hard breathing. Her legsare swelling during the day, and lessen at night. Frequent breath and crepitating sound inauscultations exam, are found from physical examinations. Artery pulse and blood pressure arenormal, but there is jugular vein obstruction when the patient in a standing position. Ictus cordisis in anterior left of axillary line/intercostals V space. Her chest x-ray shows CTR 0,69 and thelung vascular obstruction is indicated. The patient has been treated with digoxin and diuretic toalleviate her symptoms.

SCENARIO 2A 55 year old woman comes to a hospital with hardly breathe followed by a feeling of fast heartbeat when doing physical activities. In age 12, she was suffered from rheuma fever and there is amurmur sound from her auscultation since. She has got atrium fibrillation since two years ago butit is in control with digoxin 4 x o,25 mg. Vital sign : heart beat 80/min, blood pressure 130/80mmHg, respiration 16/min. Weak wet ronchi is heard on both lungs. First heart sound (S1) is loudand there is a single second heart sound (S2) with an opening snap (OS).

SCENARIO 3A 67 year old man is treated in an emergency room with severe dyspnoea. He has been in ahypertension treatment irregularly for a while, and has suffered myocardial infarct before. Aweek prior to hospitalized, the patient complained substernal chest pain for more than 30minutes, and has got worsen dyspnoea since. He could only sleep with three pillows to supporthim on bed and always awake in the middle of the night because of dyspnoea. Physicalexamination: no fever, blood pressure 160/100mmHg, heart beat 110/min, respiration 22/min and80% O2 saturation. He is pale and sweating. Wet ronchi is found at the medio-basal of both lungs,S3 and S4 are heard and no murmur. ECG shows pathological Q wave at V1-V4 .


MODULE 2 CHEST PAIN

LEARNING OBJECTIVES

General Instructional Objectives (GIOs):

After studying this module, the students will comprehend the basic concepts of chest pain andshould be able to diagnose some cardiovascular diseases relating to this symptom.

SCENARIO 1A 55 year-old man presents to the clinic with complaints of chest pain. He states that for the last6 months he has noted intermittent substrenal chest pain radiating to the left arm. The painoccurs primarily when exercising vigorously and is relieved with rest. He denies associatedshortness of breath, nausea, vomiting, or diaphoresis. He has a past medical history significantfor hypertension and dyslipidemia. His family history is notable for a father who died ofmyocardial infarction at age 56. He has a 50 pack-year smoking history. His physicalexamination is within normal limits with the exception of his blood pressure, which is 145/95mmHg, with a heart rate of 75 bpm.

SCENARIO 2A 35-year-old man presents to the emergency department with complaints of chest pain. The painis described as retrosternal, and sharp in nature. It radiates to the back, is worse with taking adeep breath, and is improved by leaning forward. On review of systems, he has noted a “flulikeillness” over the last several days, including fever, rhinorrhea, and cough. He has no pastmedical history and is taking no medications. He denies tobacco, alcohol, or drug use. Onphysical examination, he appears in moderate distress due to pain, with a blood pressure of125/85 mmHg, heart rate 105 bpm, respiratory rate 18/min, and oxygen saturation of 98% onroom air. He is currently afebrile. His head and neck examination is notable for clear mucus inthe nasal passages and a mildly erythematous oropharynx. The neck is supple, with anteriorcervical lymphadenopathy. The chest is clear to auscultation. Jugular veins are not distended.Cardiac examination is tachycardic with a three-component high-pitch squeaking sound.Abdominal and extremity examinations are normal.


SCENARIO 3A collapse 60-year-old bus driver was brought into casualty complaining of severe, sustainedcrushing pain in a band across the chest, spreading into the arms. Previously he had been well,though he smoked 10 cigarettes a day. On examination he was pale, with cold, sweaty skin. Hispulse was weak, with occasional extrasystoles (ventricular ectopic beats). His arterial bloodpressure was 90/75 mmHg. Heart sound were normal. An ECG revealed large Q waves and STsegment elevation. He was admitted with a provisional diagnosis of myocardial infarction due tocoronary artery thrombosis. Plasma analysis showed raised cardiac enzymes (lacticdehydrogenase, creatine phosphokinase, aspartate aminotransferase). He was given O2 andmorphine. A streptokinase infusion was set up to lyse the coronary thrombus, and he was alsostarted on a regular, low dose aspirin.


MODULE 3 CONGENITAL HEART DISEASES

LEARNING OBJECTIVES

General Instructional Objectives (GIOs):

After studying this module, the students will comprehend the basic concepts of Congenital HeartDiseases and should be able to diagnose some cardiovascular diseases relating to this symptom.

SCENARIO 1A ten year old girl comes with her lips and fingers blue. This has happened since she was a baby.This worsens when she cries or plays. She often have to sit on her knees when she is tiredplaying. Physical examination shows small and skinny appearance. Cyanosis appears on her lips,end of her tongue, her fingers and toes. Pulse and blood pressure are normal. Thorax examinationreveals right ventricle activity increases, followed by thrill at LSB 3. Heart sound 1 and 2 arepure, intensity increases. Systolic ejection murmur (degree 3/6 p.m LSB 4), is found. Femoralartery palpation is normal. She’s got drum stick fingers.

SCENARIO 2A four year boy is brought to a hospital because he always looks hard to breath and easy to gettired when he plays. He has suffered these since he was a baby. He never looks cyanotic. Healways suffers from recurrent cough-sniffle and sweating. Physical exam shows small and skinnyappearance. Cyanosis (negative). Pulse and blood pressure are normal. Chest X-Ray: voussurecardiac (+). Right and left ventricle activity increase. Thrill is palpable at LSB 4. Louder heartsound 1 and 2. Pansistolic murmur is heard grade 4/6, p.m. at LSB 4 spread to RSB, axillariesand suprasternal. Femoral artery is palpable normal. No drumstick fingers.

SCENARIO 3A ten year old girl comes with pain and swelling left knee, fever, palpitation. This has happenedsince three days ago. Physical exam shows cyanosis (-), pulse 140/minute regular. Blood pressure120/60 mmHg. Temperature 38 Celsius degree, DVS normal. Thorax exam: left ventricle activityincreases. Thrill is palpable at apex. Heart lining is widen. Pure heart sound 1 and 2, normalintensity. Systolic murmur is heard, diastole grade 2 – 3/6, p.m. at apex. Femoral artery istouched bounding. No drumstick fingers. Inflammatory sign at her left knee (+).

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Documents

Student Module for Cardiovascular