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SHIFA COLLEGE OF MEDICINE

STUDY GUIDECARDIO-VASCULAR SYSTEM Y-3(Spiral II)

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CONTENTS

IntroductionICON’s indexThemes of the module TOS

1. ACUTELY PAINFUL DISCOLOURED LIMB 20 %

2. CHEST PAIN 25%

3. HYPERTENSION (SILENT KILLER) 15%

4. BREATHLESSNESS WITH SWELLING 10 %

5. PALPITATIONS 15%

6. YOUNG FEMALE WITH FEVER AND PALPITATIONS

05%

7. SUDDEN DEATH 10%

Resource MaterialTeam members & People to contactGlossary

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INTRODUCTION

What this module is all about.

Welcome to CVS (Cardio vascular system), a module you would most like,

is a blend of basic and clinical sciences. The CVS is an important system as

in this modern world of science; the cardiovascular diseases are the most

common cause of death in the developed and the developing countries.

CVS related diseases are more common throughout the world, these diseases

are responsible for huge burden on economy and utilize a greater part of

health resources. You have already gone through the basic structure and

function of CVS in Spiral I and now this module will be more focused on

pathogenesis of CVS related diseases along with their clinical significance.

General OverviewIn the CVS module, you will find the true spirit of integration. The 3rd year

(CVS Y-3) module will be of 5 weeks. It will include 7 themes of diseases

which are clinically and epidemiologically important.

It will comprise themes for third year and on these themes cases have been

developed to create clinical relevance to whatever is being discussed in the

later sessions. You have already been exposed to the integrated system in

spiral 1.The format of this module would inshallah surely help you enforce

and engrip your hold on both the clinical and basic concepts.

Introduction To Exit Competencies

You are already aware of various exit competencies which we expect from a

doctor, but this module in particular will focus more on Pathogenesis,

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Clinical expertise, Health advocasy, Communication, Collaboration,

Management and professionalism.

Linkages With Other Modules

CVS Module is strongly inter-related with Respiratory and Urinary System

and they are strongly interdependent for maintenance of normal

Homeostasis. You have already encountered CVS Module in Spiral I in

which emphasis was on normal structure and functions. Now your encounter

in spiral II would be with pathogenesis and therapeutic management.

General Overview Of Learning StrategiesYour time table will guide you through the module and will also tell you

about the learning strategy being used during that very session, comprising

of SGD (small group discussion), LGIS (large group interactive sessions)

and SCIL lab sessions. A course on Basic Life Support (BLS) is arranged by

SCIL Lab to give you first hand clinical experience. In the guide you will

also come across useful tips to help you during the various sessions, your

learning resources and people to contact for your problems.

Assessment

Formative assessment will be carried out during module and summative

assessment will be held at the end of Module which will include MCQ’s,

SAQ’s and IPE’s.

CVS MODULE

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Duration : 5 weeks (August 26 to 27 September)Team Leader: Dr. Ghazala Mudassir, Dr Tahir IqbalTeam members:

1. Dr. Talat Ahmed2. Dr. Riffat Nadeem3. Dr.Samina Ghayur4. Dr. Mahwish Majid Bhatti5. Dr AbidaShaheen6. Dr Fahad Azam7. Dr Zubaida Zain8. Dr Tehzeeb Zehra9. Dr. Gemza Shah10.Dr. Arooj Anthony11.Dr. Imran Khan Jehangir12.Dr. Syeda Hanna Fatima13.Dr. Muhammad Umer Farooq14.Dr. Syeda Sitwat Mehmud15.Dr. Zubia Arshad16.Dr. Ali Azeem17.Dr. Sara Rathore

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You will find symbols throughout the module which indicate some

action on your part as follows:

Introduction to case

Learning objectives

SCIL sessions

Critical questions

Key words

Resource material

Web address link

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THEME 1: SWOLLEN LIMB (Thrombosis)

CASE 1

Mrs. Ahmed a 40-year-old woman presents with a 10-hour history of

gradually increasing pain and swelling in her left calf. There is no history of

trauma to the leg. She started taking oral contraceptive pills (OCP) 1 week

ago. Her left calf is erythematous, warm and tender to palpation, and is

4 cm thicker than the right calf. Vital signs are normal. Pulses are 2+, and

there is 2+ lower extremity pitting edema.

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CRITICAL QUESTIONS

What is the most concerning possibility at this time?

What are the risk factors for DVT?

What complications can occur?

How you will manage a patient with DVT?

Knowledge

1. Enumerate relevant investigations e.g. EKG, Echo, BNP

2. Describe the dosage, pharmacokinetics, mechanism of action, adverse

effects, drug interactions & contraindications of the drugs used in the

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management of DVT.

Learning Objectives

1) Describe the pathophysiologic causes of edema

2) Describe hyperemia, congestion and hemorrhage. Describe normal

hemostasis.

3) Describe normal hemostasis, pathogenesis of thrombosis and its

complications. The students should know the medicolegal significance of ante

and post mortem clot.

4) Describe the pathogenesis and morphological appearance of infarction.

5) Describe the role of anti-coagulant drugs.

SKILL

The student should identify;

1) The histopathological slides of thrombosis, edema

2) Order appropriate tests to document DVT

3) Select appropriate plan for DVT treatment

4) Counsel patient on DVT & its complications

ATTITUDE

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1) Identify risk factors and Risk factors reduction strategies.

2) Health promotion of disease prevention

3) Demonstrate general professional attitude when dealing with

patients

4) Counseling for prevention and its complication

Theme 2: CHEST PAIN

CASE 1

Mrs. Ahmed now presents with an 8 weeks history of substernal chest

tightness and pressure that radiates to the left arm. The discomfort occurs

predictably after 5 minutes of exercise and causes her to stop all activity.

Her symptoms gradually increase in intensity and resolve within 3-4 minutes

of rest. Breathing and position don’t change her symptoms .She doesn’t have

any dyspnea, diaphoresis, nausea or vomiting. She has a history of

hypertension that is controlled with hydrochlorothiazide. Her father has

diabetes and both parents have hypertension. She has smoked a pack of

cigarettes a day since she was 25 years old. Physical examination, vital signs

and resting EKG are normal.

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Anterior Ischemia (Angina)

CRITICAL QUESTIONS

What is the most likely cause of her symptoms ?

How is stable angina managed ?

Why is an exercise stress test recommended in patient with

stable angina?

How is revascularization of the coronary arteries achieved ?

Should this patient undergo percutaneous coronary intervention

(PCI) or coronary artery bypass grafting (CABG) ?

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Case 2

Mrs. Ahmed presented in medical emergency with c/o severe crushing chest pain,

tachycardia and edema for the last 1 hour. She has a h/o stable angina on exertion that is

usually relieved by sub-lingual nitroglycerine. Her current symptoms occurred at rest and

have not responded to nitroglycerine at home. She has h/o hypertension and smoking. She is

sweating and appears anxious. On examination: Pulse 110/min, BP 140/85 mmHg, R/R

22/min, oxygen saturation 98% on room

air,Temperature37.6C.CVS=S1+S2+0,Chest=Clear.

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Acute Anterior wall MI

Coronary angiography. Showing triple vessel disease

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Learning ObjectivesThe student should be able to :

Enumerate various causes of cell injury. Describe the various series of events resulting in cell injury eg

following ischemic insult, Mitochondrial damage, intracellular Ca influx, ROS & Defects in membrane permeability.

Differentiate between Reversible & Irreversible cell injury on basis of histological features.

Define necrosis & describe its mechanisms . Differentiate & describe the gross & microscopic features of various

types of necrosis. To recognize the histological features & diagnose apoptosis (like cell

shrinkage,chromatin condensation , apoptotic bodies etc) To be able to describe Mechanisms of development of apoptosis (The

Extrinsic,Intrinsic pathway,Execution phase & removal of dead cells). To describe various subcellular responses to injury eg.lysosomal

catabolism,smooth muscle hypertrophy etc by microscopic analysis. To enumerate the various intracellular accumulations with their salient

histological features , their correlation with various diseases To identify the causes, morphology & pathogenesis of pathologic

calcification. Describe the causes, pathogenesis & complications of myocardial

infarction with clinical correlation of continuum of IHD (stable

angina, unstable angina, CHF, Arrhythmias)

Describe the dosage, contraindication, mechanism of action and

cautions of the drugs used in Angina and Myocardial Infarction;

(Fibrinolytics, Drugs used to decrease ischemia, Drugs used as

adjunct treatment)

Formulate an evidence based plan for ACS.

Discuss the causes, pathogenesis & complications of

hypercholesterolemia.

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Increased cholesterol levels with various endothelial changes.

Relate Atherosclerosis with organ dysfunction (myocardium).

Discuss Atherosclerosis & Differentiate between the concepts of fixed

vessel narrowing and Plaque rupture.

SKILLS

The student should be able to: Identify histopathological slides of coagulation necrosis, caseation

necrosis To identify histopathological slides of intracellular events like fatty

change, hemosiderosis, cholestasis, melanin pigmentation, anthracosis and dystrophic calcification.

Take history of chest pain (intensity, site, radiation, associated

symptoms)

Perform general physical examination & detailed CVS examination

Differentiate between various components of pulse (rate, rhythm,

volume, character) (revisit)

Identify the heart sounds (normal, abnormal) (S1, 2, 3, & 4) and added

sounds

Formulate differential diagnosis of chest pain

Choose appropriate labs: laboratory tests for ACS e.g. cardiac

enzymes (CK-MB, Troponins, and LDH) and understanding their time

of rise and diagnostic preference

Identify and differentiate gross and microscopic morphological

features of live and dead tissue and to determine the cause of death in

that tissue

EKG : basis of cardiac electric activity, ST depression and elevation

(revisit)

CXR &Echocardiogram

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ATTITUDE

Counseling on risk factors (DM, HTN, dyslipidemia, smoking,

sedentary life style etc) and risk factors reduction strategies.

Demonstrate professional attitude when dealing with patients

Counseling for primary & secondary prevention of heart disease

Nutritional counseling

CRITICAL QUESTIONS

What is the most likely diagnosis?

How will you investigate this patient ?

What are the initial steps in the management of this patient?

Which thrombolytic agent should this patient receive?

What revascularization method should this patient undergo?

What tests are recommended prior to discharge for risk satisfaction?

What medications should this patient receive?

What additional therapy would you recommended if the patient had

evidence of systolic heart failure with an ejection fraction of 30

percent on Echocardiography?

Case 3

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The condition of Mrs. Ahmed deteriorated. Fifteen hours later, blood

pressure is 90/60, pulse is 120 bpm, respirations are 25/minute, and oxygen

saturation is 94%. Skin is cool and clammy, and 14 cm of JVD is present.

New crackles are appreciated in both lung bases. Urine output is 0.2 mg/kg

per hour.

LEARNING OBJECTIVES

1. Discuss the causes, types, pathogenesis & clinical features of

cardiogenic shock and differentiate it from other types of shock.

2. Explain the treatment of various types of shock.

Critical Question

1: What is the likely cause of shock?

2: What are the next steps in management?

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4: What is a Swan-Ganz catheter? What are the Swan-Ganz findings in

different types of shock

5: PCWP is 21 mm Hg (normal 6 to 12). Hypotension, elevated PCWP,

and other signs of shock persist despite vasopressors. Is there any

treatment for patients with refractory cardiogenic shock?

THEME 3: HYPERTENSION

CASE

A 50 years old man presents to the clinic for an annual check-up. He does not have any prior medical history, hospitalization or surgery. He smokes half a pack of cigarettes a day and drinks a glass of wine every night. Physical examinations are unremarkable. Temperature, pulse and respiration are within normal limits .Blood pressure is 135/80., cvs=S1+S2+0.The patient asks if his BP is normal.

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Typical ECG in Hypertension showing LVH with lateral strain pattern

LEARNING OBJECTIVES

KNOWLEDGE Draw a concept map for pathways /mechanism leading to

hypertension.

Classify and select anti hypertensive drugs and discuss the dosage,

pharmacokinetics, mechanism of action, adverse effects and drug

interaction of various anti hypertensive’s

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SKILL

Take focused history of a hypertensive patient

Record blood pressure in different positions

Perform necessary bed side clinical evaluation and order pertinent

laboratory tests

ATTITUDE

Identify risk factors and risk factors reduction strategies.

Demonstrate professional attitude when dealing with patients

Counseling for primary & secondary prevention of HTN and its

complications

Nutritional and life style counseling.

CRITICAL QUESTIONS

What non-pharmacological measures you will advise to this patient?

During his follow up appointment 1 year later, his BP readings are

above 145/90 mmHg.

What anti-hypertensive you will start.

What end-organ damage caused by hypertension?

How does malignant hypertension differs from accelerated

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hypertension and hypertensive encephalopathy ?

How does hypertensive emergency managed?

THEME 4: BREATHLESSNESS AND SWELLING (CCF)

A 58 years old man with 10 year h/o hypertension presents with dyspnea and

dry cough that has been progressively worsening over the last 6 months.

Initially he experienced dyspnea only after a brisk 1 km walk. He now has

dyspnea climbing up a few flight of stairs. On lying down, his symptom

worsen and he often needs three to four pillows to fall asleep (orthopnea).

Auscultation of the heart reveals a S3, S4 and a 1/6 blowing holosystolic

murmur heard best at the apex that radiates to the axilla. Apex beat is

displaced to the left. There are bilateral basal crackles. JVP is raised

(9cm).The liver edge is tender and is 4cm below coatal margin (tender

hepatomegaly). He has a marked peripheral edema. BP is 170/100 mmHg

and pulse is 80/min, regular.

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Learning Objectives1.Enumerate relevant investigations eg. EKG, Echo, BNP.

2. Describe the dosage, pharmacokinetics, mechanism of action, adverse

effects, drug interactions and contraindications of drugs used in heart failure.

SKILL

Take history and physical examination of patient with heart failure.

ATTITUDE

1.Address risk factors and risk factor reduction strategies.

2.Demonstrate professional attitude when dealing with patients

3.Counseling for primary & secondary prevention of HTN and its

complications

4.Nutritional and life style counseling.

CRITICAL QUESTIONS

1. What is the most likely diagnosis?

2. What are the most important causes of congestive cardiac failure?

3. What investigations would you advise this patient?

4. How will you treat a patient with CCF?

5. What are the symptoms of Digoxin toxicity and how will you manage

it?

6. What do you mean by pulmonary edema and how will you manage it?

THEME 5: PALPITATIONS

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CASE 1 :

A 76 years old man presents with a 1 week history of intermittent

palpitations. He is currently asymptomatic. He has a H/O hypertension that

is treated with hydrochlorthiazide and lisinopril. He is alert and

oriented .Heart rate is 120/min and pulse is irregular .He is afebrile .Bp is

130/80 mmHg .ECG revealed irregularly irregular rhythm with no

identification P waves and wavy base line.

Atrial Fibrillation with fast ventricular rate

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Atrial Fibrillation with slow ventricular rate

CRITICAL QUESTIONS

What is the most likely diagnosis ?

What are the causes of atrial fibrillation ?

How you will manage a patient with atrial fibrillation ?

Why is cardioversion not recommended initially in stable patient with

atrial fibrillation?

How would initial management have differed if the patient presented

with palpitations and tachycardia and his Bp was 80/60 mmHg ?

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What is synchronized cardioversion ? How does it differ from

defibrillation ?

CASE 2 :

A 30 years old man presents with palpitation and light headedness .ECG

revealed tachycardia with regular rhythm and narrow QRS complex

SVT

CRITICAL QUESTIONS

What is the most likely diagnosis?

What is the mechanism of SVT ?

What are the pharmacological and non-pharmacological

measures of treatment ?

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CASE 3:

A70 years old man, with a history of systolic heart failure .ECG revealed

that there is no PR interval lengthening and a number of normal impulses are

conducted. Suddenly , the P wave fails to conduct and there is no QRS

complex.

IIo Heart block (Mobitz type 2) with 2:1 conduction with Io Heart block (prolonged PR)

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CRITICAL QUESTIONS

What is the diagnosis ?

What is the underlying mechanism ?

What further complication can occur ?

How will you manage this patient ?

LEARNINGT OBJECTIVES

KNOWLEDGE

Explain the mechanism and etiology of brady and tachyarrhythmia

Describe indication of anti-arrhythmic drugs, their mechanism of

action, pharmacokinetics, adverse effects, interactions &

contraindications

Identify Indications for CPR (DC shock, TPM and PPM) in a patient

of arrhythmias

Attend the course of BLS and ACLS

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SKILL

Interpret arrythmias on ECG (Identify Arrhythmias as Brady or

tachyarrhythmia)

Perform BLS and CPR

ATTITUDE

Identify risk factors and risk factors reduction strategies.

Demonstrate health promotion of disease prevention

Demonstrate general professional attitude when dealing with patients

Counseling for its complications

Nutritional and life style counseling

THEME 6:YOUNG FEMALE WITH FEVER AND PALPITATION

CASE 1 :

A 15 years old female presented to the medical clinic with a three weeks

H/O joint pain.It initially started in her knees followed by her wrists.She

recalls having a sore-throat two weeks before her symptoms began .Physical

examination is significant for three firm,symmetric and painless

subcutaneous nodules over the olecranon processess.There are erythematous

non-pruritic plaques with a pale center on the trunk .Auscultation of the

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heart reveals 2/6 systolic murmur, that is heard best at the apex and radiates

to the axilla.Vital signs are temperatur.38.9 C,pulse=90/m, R/R

=12/m ,BP=110/70mmHg and oxygen saturation 95 percent.

CRITICAL QUESTIONS

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What is the most likely diagnosis ?

What are minor and major criteria ?

How is acute rheumatic fever treated ?

CASE 2 :

A 30 years old male presented to the medical clinic with a

three weeks history of low-grade fever, malaise and

arthralgia .He has a history of intravenous drug abuse .He has no other prior

medical history .Physical examination is significant for 1/6 blowing murmur

heard best at the left lower sternal border that increases with inspiration and

decreases with expiration.There are numerous recent injection marks on his

right and left arms, Vital signs are temperature.39 C,Pulse :90/m,

respirations (R/R):15/min, BP=110/75 mmHg.

CRITICAL QUESTIONS

What is the diagnosis?

What are the important physical findings of infective

Endocarditis?

What investigations you will advise?

What causative organisms are most likely in this patient ?

What is major and minor criteria for diagnosis of infective

endocarditis?

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LEARNING OBJECTIVES

KNOWLEDGE

Describe diagnostic criteria, etiologic organisms, sequelae,

prophylaxis, complications of Infective endocarditis.

Outline the principles of management of a patient of Infective

endocarditis.

SKILL

Surface marking of cardiac valves on SP (simulated patient) (revisit)

Take history and perform physical examination of a patient with

valvular heart disease.

Identify systole and diastole murmurs on mannequin.

ATTITUDE

Counseling risk factors and Risk factors reduction strategies.

Discuss health promotion of disease prevention

Demonstrate general professional attitude when dealing with patients

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Counseling for its complications

Life style counseling

THEME 7: SUDDEN DEATH

CASE

This is an unusual case of homicide where a young woman was found dead

in her bath, slumped forwards in a kneeling position with one breast resting

against a chrome tap. The left arm was trailing over the edge of the bath, in

which was the usual level of water plus an electric fan heater immersed near

the feet. To all intents and purposes it appeared that the woman, while taking

her bath had accidentally slipped in the bath and drowned. This is not a very

unusual mode of death. Several people have accidentally died in this way.

As regards the heater in the water, it was assumed that when the woman

must be struggling to find her way out, her legs may have got entangled in

the cable wire somehow and she must have accidentally dragged the heater

in the bath.

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AUTOPSY FINDINGS: -

However while conducting the post mortem examination; the autopsy

surgeon noted two curious marks on the body. The first was on the left

breast and the other was over the inside of her left arm near the axilla. These

were the marks produced by electricity. This indicated that this could be a

case of homicide. Subsequent investigations revealed that it was indeed a

case of homicide and the husband was involved in that ghastly murder. So

just two insignificant looking marks took the perpetrator of crime to the

gallows.

After the suggestion of the autopsy surgeon, the police called the expert

electricians and asked them to examine the concerned heater. Surprisingly it

was found that the third `earth' wire was disconnected from the earth pin

inside the plug. This clearly established the intentions of the murderer who

incidentally turned out to be the woman's husband himself. Since the enamel

lining of the bath can not allow the current to pass through, the earthing of

the current could only occur through the bath water via the chrome waste

pipe. The woman was subsequently pushed against the tap by her husband in

such a way that her left breast touched the metal tap. This started another

path for the current to pass

out-through the body and then through the metal tap. This path presumably

took the woman's life.

OBJECTIVES

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At the end of the session, the students should be able to

Knowledge:

• Enlist the criteria of Certification of Death according to WHO

standards.

• Differentiate between somatic and molecular death

• Enlist sudden natural and unnatural causes of death

• Differentiate between mode, manner, mechanism and cause of death.

• Determine time since death in different environmental and

pathological conditions

• Describe the factors affecting time since death

• Relate the immediate, early and late changes after death to the mode ,

manner, mechanism and time since death

• Identify post mortem chemical and path physiological changes after

death and the factors influencing such changes

• Identify the poisons that can lead to a cardiac event.

Skills:

• Complete/ fill death certificate on the basis of standards laid down by

WHO

Attitude

• Recognize the ethical issues regarding death

• Develop sensitivity towards death, the dying patients and the bereaved

family

CRITICAL QUESTIONS

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What is the basic criteria of certifying death

What are the factors affecting time since death

What are the differences between the mode, manner and

mechanism of death

How would you calculate the time since death after reviewing

the changes after death

Recommended Reference Books:

Medicine: Kumar and Clark clinical medicine 7th edition

Davidson’s principles and practice of Medicine

Current medical diagnosis and treatment 2011

Pathology: Robbins Pathologic Basis of Disease

Microbiology: Jawets, Melnick & Adelberg’s Medical Microbiology

Pharmacology:

• Basic & Clinical Pharmacology Bertram G. Katzung 11th edition

• Lippincott’s Pharmacology latest edition

• Essentials of medical pharmacology, JayPee, Tripathy, 6th edition.

Forensic: Parikh’s Textbook of medical Jurisprudence.

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