UNIVERSITY OF SANTO TOMAS

FACULTY OF MEDICINE AND SURGERY

DEPARTMENT OF MEDICINE
MEDICINE II CV MODULE
SY 2015 2016

CARDIOLOGY MODULE

UNIVERSITY OF SANTO TOMAS

FACULTY OF MEDICINE AND SURGERY
DEPARTMENT OF MEDICINE
MEDICINE II
AY 2015 - 2016

CARDIOLOGY MODULE
GENERAL DESCRIPTION
The Cardiology Module is a 7- 8 meetings course on the study of the common diseases of
the cardiovascular system. The learning process will focus on the clinical recognition and
management of the disease through clinical case conferences, lectures, small group discussions
(SGD), ward works and workshops.
ENTRY COMPETENCIES:

1. Knowledge on the aanatomy of heart and blood vessels

2.
3.
4.
5.
6.
7.

Knowledge on ccardiac physiology (cardiac cycle)

Knowledge on the pathogenesis of various cardiovascular symptoms
Identify all the problems present in any given case
Write satisfactory history for each cardiovascular symptom or disease
Perform complete and correct physical examination (cardiovascular PE)
Basic knowledge of ECG, CXR, ECHO and common laboratory examinations (cardiac
biomarkers, lipid profile)
8. Knowledge on mechanism of action, indications and side effects of the different
cardiovascular drugs (e.g. diuretics, antihypertensive, anti-arrhythmic, anti-ischemic)
9. Perform correct Basic Life Support
TERMINAL COMPETENCIES:
Given a case with a cardiovascular disease, the student should be able to:
a)
b)
c)
d)

State the problems of the patient

Formulate a clinical assessment/ priority diagnosis
Enumerate the differential diagnoses
Identify the required diagnostic tests/procedures and justify need for such
tests/procedures
e) Make a complete cardiac diagnosis (etiology, anatomic, physiologic, functional,
objective)
f) Outline a logical management scheme including pharmacologic and nonpharmacologic measures
g) Discuss possible disease complications
h) Outline preventive measures
i) Recognize and treat any complications of therapy
j) Make a concise and written summary of the case (Medical abstract)

LEARNING ACTIVITIES
Clinical Case Conference
Objectives:

To present an interesting CV case of multidisciplinary problem that was actually admitted

at UST Hospital
To dissect the case being presented, and present how the patients history, physical
examination findings and laboratory results aided in ruling out the other disease entities to
arrive at a logical diagnosis
To present the associated complications of a disease entity
To give a rational approach to the treatment of disease and the complications that may
arise from such treatment
To arrive at other future plans to lessen morbidity and mortality
To discuss ethical principles applicable in a case

Special Lectures
Objectives:

To give a lecture on topics that have a great impact in the community due to its associated
morbidity and high incidence of mortality
To give updates on the current therapeutic recommendations
To give a lecture on difficult and complicated topics that may need clarification

Workshops
Objectives of Cardiac Auscultation Workshop

To correlate anatomy and physiology of the CV system with cardiac auscultatory findings
To teach the students on how to correctly identify the different heart sounds
To enable the students to listen to different murmurs of valvular and congenital heart
disease.

Objectives of ECG workshops

To demonstrate how a 12 lead ECG is done

To give the uses of the 12 lead ECG
To teach the students how to read the 12 lead ECG including the rate, axis, PR interval,
QRS interval, QT (QTc) interval and common rhythm abnormalities
To guide the students on how to recognize normal from abnormal ECG findings
To guide the students on the proper interpretation of an electrocardiogram

Objectives of the Echocardiography Workshop

To demonstrate how an echocardiogram and Doppler study is done

To teach the students the principles of echocardiography
To give the uses of the echocardiogram and Doppler study
To guide the students on the proper interpretation of the echocardiogram

Objectives of Non-invasive Cardiac Imaging Workshop

To introduce other non-invasive cardiac imaging (Nuclear Cardiology, Magnetic

Resonance/Computed Tomography)
o How they are done
o Principles behind each imaging
o Their indications and clinical correlation

To introduce chest radiography in relation to a cardiac patient

o Correlate cardiac anatomy and physical examination findings with chest X-ray
findings
o Indications of chest X-ray in the evaluation of a cardiac patient
o Recognition of cardiomegaly and chamber enlargement
o Recognition of pulmonary congestion

Objectives of cardiac catheterization and coronary angiography workshop

To understand the principles of cardiac catheterization and coronary angiography

To know the indications and contraindications of cardiac catheterization, coronary
angiography and cardiac interventions
To know the risks involved in cardiac catheterization
To identify normal coronary arteries from those with coronary stenosis
To identify the different pressure waveforms during hemodynamic assessment
To identify the complications that may be encountered by patients undergoing cardiac
catheterization

Small Group Discussion

Objectives

To give the students opportunity to discuss with their facilitators the cases that are
commonly encountered in the specialty
To guide the students to a rational diagnostic approach in a given case
To enable the students to formulate a complete treatment plan, including
preventive measures

Decury / Ward Work

To give the students an opportunity to study an actual patient in the ward, do a correct
history taking and physical examination, identify the pertinent problems present, arrive at a
correct diagnosis and plan a management scheme which includes both pharmacologic
and non-pharmacologic measures
To provide a more congenial faculty student contact, where students are encouraged to
discuss certain issues more openly in a small group setting

Examinations

Short quizzes with maximum of 20 items each on reading assignments and workshop
topics
10 item quizzes about the case after a clinical case conference
Module examinations (shifting exam) mostly problem solving questions

University of Santo Tomas

Faculty of Medicine and Surgery
Department of Medicine
Section of Cardiology
Small Group Discussion Case A
A 20- year-old, female, factory worker, consulted because of dyspnea. Two years prior to
consultation, she started to experience shortness of breath while climbing 1 flight of stairs or lifting
heavy objects. No consultation was done. A year later, he was not able to work anymore because
of difficulty of breathing at rest which was accompanied by orthopnea, paroxysmal nocturnal
dyspnea, and pedal edema. She consulted a physician in a community health center and was
prescribed Furosemide 40 mg BID which she took for about a week. Symptoms abated but she
did not go back for follow up. She took Furosemide 40 mg irregularly whenever he is
symptomatic. One month prior to consultation, she was unable to lie down on bed because of
difficulty of breathing despite taking Furosemide. This prompted her to consult at our institution
and was eventually admitted.
Physical examination:
Conscious, coherent in cardio-respiratory distress, diaphoretic
BP 110/70 PR 125 /min RR 26/min T 37C BMI 20
Icteric sclerae, JVP 9cm at the angle of the mandible, CAP rapid upstroke, gradual downstroke
Suprasternal, intercostal and subcostal retractions. Hyperdynamic precordium. Apex beat at 5th
LICS anterior axillary line. RV heave. PA lift, Systolic thrill at the left parasternal and pulmonary
areas. At the apex, S1 is loud followed by a grade 4/6 holosystolic murmur heard louder during
inspiration. S2 is also loud. At left the base, S1 is soft followed by a grade 4/6 midsystolic
crescendo-decrescendo murmur. S2 is widely split and relatively fixed in relation to respiration.
Crackles are heard over both lung areas. Liver span is 20 cm at the LMCL Lower extremities are
swollen bilaterally up to the level of the knees. No cyanosis
1. What is the most plausible etiologic diagnosis?
2. What is/are the anatomic abnormalities present?
3. What is the physiologic diagnosis?
4. What is the functional classiffication?
5. What is the objective assessment?
6. What causes the wide and fixed splitting of the second heart sound?
7. What are the different types of this cardiac disease?
8. What anxillary procedures would you request?
9. How would you manage this patient?
10. Definitive plans
11. Preventive plans

University of Santo Tomas

Faculty of Medicine and Surgery
Department of Medicine
Section of Cardiology
Small Group Discussion Case B
This is a case of MTS, 68-year-old, female, retired public high school teacher, who
consulted at your clinic due to chest heaviness. Three months prior to consult, patient
experienced intermittent chest heaviness which occurred while doing household chores such as
sweeping the floor or washing the dishes. The pain would resolve after resting for several
minutes. She consulted a private physician and recalled a BP of 160/90. A 12 L ECG was done,
however the result was unrecalled but she was told that there was a probable obstruction in the
arteries of her heart. She was prescribed with ASA 80 mg/ tab 1 tab OD, Amlodipine 5 mg/tab 1
tab OD and ISMN 30 mg/tab 1 tab OD, ISDN 5 mg/tab 1 tab/SL PRN for chest pain. Patient was
compliant with ASA, but stopped taking ISMN due to headache after taking the medication. One
day prior to admission, patient experienced chest heaviness after a heated conversation with her
eldest daughter. Patient took ISDN sublingually which afforded relief of chest pain. Patient as
worried that the chest pain might recur prompting her to consult at your clinic for work up.
She is a known hypertensive for 10 years, with Usual BP- 140/90, Highest BP- 180/100,
compliant with intake of Amlodipine 5 mg/tablet 1 tab OD, ASA 80 mg/ tab 1 tab OD, ISDN 5
mg/tab 1 tab PRN for chest pain.
Personal History:

Non smoker
Non alcoholic beverage drinker
Family History:
(+) premature CAD (sister at age 38 & brother at age 45)
(+) hypertension father and mother
(+) DM mother
Review of Systems: (+) polydipsia (+) polyuria
At your clinic, BP = 130/90, HR 95 bpm, regular, RR 20 cpm, with warm moist skin, neck
veins not distended, JVP measured 3 cm at 30o. There were no rhonchi, wheezes or crackles.
Except for AB at 6th LICS AAL, diffused and sustained, cardiac findings are normal.

Guide Questions:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.

What is your complete cardiovascular diagnosis?

Differentiate between atherogenesis and atherothrombosis:
What are the risk factors for coronary artery disease?
Definition of angina
How do you evaluate patients with chest pain by history and physical examination?
Discuss the classification of angina pectoris by the Canadian Cardiovascular Society
Discuss the algorithm in Clinical assessment of patient with angina
Discuss algorithm for evaluation of the patient with known or suspected ischemic heart
disease
Give differential diagnoses in patients with chest pain.
What are the laboratory examinations and ancillary procedures you will request for the
patient?
Discuss the algorithm for the management of the patient with Ischemic Heart Disease.
Discuss the management for risk factor for IHD
What are the 2 major goals in the treatment of IHD and how do you address each one?

University of Santo Tomas

Faculty of Medicine and Surgery
Department of Medicine
Section of Cardiology
Small Group Discussion Case C

SM, an 86-year-old male consulted because of recurrent syncope.

History started 5 months prior, when he started to experience intermittent dizziness and
easy fatigability. There was no chest pain or headaches. He consulted his private
physician who prescribed betahistine 8 mg/tab as needed for the dizziness.
Three months prior, still with the persistence of dizziness and easy fatigability, he started
to experience episodes of loss of consciousness occurring for 5-6 seconds. The episodes
occurred 1-2 times a month. The patient claimed to feel well immediately after the
episodes with no weakness, chest pains nor dyspnea.
Sometimes, the patient
experienced symptoms of lightheadedness, and visual blurring prior to the episodes. He
consulted a neurologist and was diagnosed to have a seizure disorder. He was given an
unrecalled anti-epileptic medication.
One month prior, he noted increase in the frequency of loss of consciousness, now
occurring at least once a week. This prompted consultation:
Patient had no history of diabetes or hypertension. He was diagnosed to have a transient
ischemic attack 2 years ago where he was admitted because of left sided weakness. He
was maintained on Aspirin 80 mg/day.
He was also diagnosed to have glaucoma 3 years ago, and maintained on timolol
ophthalmic solution.
Patient underwent laparoscopic cholecystectomy for cholelithiasis 5 years prior.
He is a previous smoker, 8 pack years, and stopped 6 years ago; and an occasional
alcoholic beverage drinker.
Family History was positive for hypertension and stroke.
On physical examination, the patient was conscious, coherent and ambulatory, and not in
acute cardiorespiratory distress. Vital signs showed: blood pressure 150/90 mm Hg, pulse
rate 38 bpm, respiratory rate 14/min and temperature 36.6 C. His skin was warm and dry.
HEENT examination was normal. There was no jugular venous distention noted. JVP was
3 cm at 30 degree angle. Chest expansion was symmetrical with no retractions and clear
breath sounds. He had an adynamic precordium, with the apex beat at the 5th LICS MCL,
non-diffuse and non-sustained, no heaves or thrills. He had normal Sl and S2 sounds; no
rubs, gallops, or murmurs were heard. Abdomen was normal except for surgical scars
secondary to his laparoscopic cholecystectomy. He had no edema and his peripheral
pulses were all ++.
Upon examination, a 12 lead ECG was done. 24 hour Holter and 2D Echocardiogram
were likewise requested.
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Ancillary Examination
12 lead ECG:

24 hour Holter:

Interpretation:
12 Lead ECG

Chest X ray

2 D Echocardiogram
24 Hour Holter

Severe sinus bradycardia, HR 31 bpm

Left ventricular hypertrophy by voltage
Nonspecific ST T abnormalities
Lung fields are clear
Diaphragm not elevated
Heart is not enlarged
Concentric LVH with good wall motion and contractility
Sinus bradycardia with frequent long sinus pauses, longest
pause 5.8 seconds, with occasional junctional escape beats
Occasional premature atrial complexes
Intermittent atrial fibrillation with rapid ventricular response

Quide Questions
1. What is the etiologic diagnosis?
2. What are the anatomic changes present?
3. What are the physiologic changes present?
4. What is the NYHA functional class and why?
5. What is the objective assessment of cardiovascular disorder and why?
6. What is the definition of syncope and what are the causes of syncope?
7. How do you differentiate syncope from seizure?
8. What are the common causes of syncope?
9. Discuss the diagnostic workup of syncope.
10. Discuss the immediate management of syncope.
11. Discuss the immediate management of bradycardia.
12. How will you manage this patient, both acute and long-term? Give the preventive
plan.

University of Santo Tomas

Faculty of Medicine and Surgery
Department of Medicine
Section of Cardiology
Small Group Discussion Case D

A 47 y/o male, call center agent, consulted because of BP elevation. During their
annual PE, he was noted to have a BP of 160/90. He claims he just came from a night
duty when he had his PE. He denied having any symptoms
Past History: No history of HTN with usual BP of 120-130/90
Current Health Status and Risk Factors: No regular exercise. Fond of eating dried fish
and puts fish sauce (Patis) in all his food. 16 pack-year history of smoking. Drinks alcohol
2-3x/week, consuming 5-10 bottles of beer per session. Denies illicit drug use or steroid
use.
Family History: HTN both parents and one sibling, DM father
Personal and Social History: unremarkable
Review of System: 10 lbs weight gain for the past 6 months
Physical Examination:
Conscious, coherent, not in cardiorespiratory distress
BP 160/ 100

PR 90 BPM regular

RR 20 CPM

Ht 157 cm

Wt 65 kg

BMI: 26.3

Fundoscopy: (+) AV nicking

Neck: (-) thyroidmegaly
CV: JVP 3cm at 30o, Carotid pulse has brisk upstroke with gradual downstroke, (-) carotid
bruit, peripheral pulses (++) bilateral. Precordium is dynamic. Apex beat at the 5 th LICS
MCL, sustained but not diffuse. (-) lifts, heaves, thrill. Loud S1 followed by soft S2 at
apex. Soft S1 with accentuated S2 at base. No murmurs.
Respiratory: unremarkable
Abdomen: No masses palpated, (-) bruit
Neurologic exam: unremarkable
GUIDE QUESTIONS:
1. How do you diagnose hypertension (HTN)?
2. What is the BP cut-off to diagnose HTN
A. in the clinic
B. at home
C. on 24hrs ambulatory measurement?
3. What is the most plausible etiologic diagnosis?
4. What is/are the anatomic abnormalities present?
5. What is the physiologic diagnosis?
6. What is the functional classification?
7. What is the objective assessment?
8. What are the risk factors for hypertension in general and those found in the patient?
9. What is the BP classification of our patient?
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A. JNC 7
B. ESC
10. What are the basic laboratory tests for initial evaluation of HTN and what do you want
to see in those laboratory tests?
11. When do you start treatment?
A. Lifestyle modification
B. Pharmacologic intervention
12. What are the lifestyle interventions for hypertension?
13. What are the first and second line pharmacologic agents for hypertension?
A. How do they act?
B. What are their special indications?
C. What are their contraindications/side effects?
14. What are the possible complications of HTN and what is the impact of treatment?
15. What are the measures to prevent the occurrence of hypertension?

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