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SHIFA COLLEGE OF MEDICINE

STUDY GUIDE

CARDIOVASCULAR SYSTEM- 1573

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CONTENTS

 Introduction

 ICON’s index

 Themes

 Team members

 Resource Material

 Glossary
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INTRODUCTION
What this module is all about?
Welcome to CVS (Cardio vascular system), a module which 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 morbidity and mortality both in
the developed and the developing countries.
You have already gone through the basic structure and function of CVS in Spiral I and
now more focus would be laid on related concepts of general pathology and some
common CVS related diseases.

General Overview
The 3rd year (CVS Y-3) module will be of 5 week duration. It will include 8 themes
under which the course would be covered.
One or more cases for each theme are developed to create clinical relevance to whatever
is being discussed in the later sessions which would surely help engrip your hold on both
the basic and clinical concepts.
General Overview Of Learning Strategies
Your time table would tell you the layout of teaching strategies for the upcoming week
comprising of SGD (small group discussion), LGIS (large group interactive sessions),
practical laboratory and formative assessment sessions. 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 at periodic intervals during module and
summative assessment will be held at the end of module which will include MCQ’s and
SAQ’s. There will be IPE (Integrated practical examination) at the end of block ie after 3
modules.
In order to get a good hold on CVS, you should come prepared for the coming session
after looking at the weeks’ timetable. You should mark your difficulties and take help
from your facilitators and senior faculty. Lastly be punctual as this would be rewarding
not only in this module but in your professional carrier as well.

GOOD LUCK!
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ICONS:

Introduction to case

Learning objectives

SCIL sessions

Critical questions

Resource material
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THEMES

1. A MAN WITH CHEST PAIN

2. A CASE OF SHOCK

3. A LADY WITH HEADACHE & PALPITATIONS

4. A CASE OF BREATHLESSNESS WITH ANKLE SWELLING

5. A LADY WITH SWOLLEN LOWER LIMB

6. A PATIENT WITH PALPITATIONS AND SYNCOPE

7. A YOUNG MALE WITH FEVER AND HEART MURMUR

8. A CASE OF SUDDEN DEATH

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TEAM MEMBERS

Duration: 5 weeks

Module Director:
Dr. Ghazala Mudassir
Module Co-Director
Dr. Sajida Naseem

Team members:
1. Dr. Rifat Nadeem
2. Dr. Mohammad Arshad
3. Dr. Mahwish Majid Bhatti
4. Dr. Mahwish Niaz
5. Dr. Safina Ahmed
6. Dr. Maryam Habib
7. Dr. Abida Shaheen
8. Dr. Fahad Azam
9. Dr. Umme Kulsoom
10. Team III
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THEME 1: A MAN WITH CHEST PAIN

Case 1:
Presenting complaints:
A 55 year old smoker presented with:
 severe central chest pain
 sweating
 nausea
 breathlessness for the last one hour.
History of Presenting Complaints
The central chest pain started about an hour back. Its severity is agonizing, compressing
in nature and radiating to left shoulder. There is profuse sweating and palpitations.
Past History
Diagnosed with hypertension five years back.
Drug History
Taking anti-hypertensive therapy however the compliance is poor.
Family History
His father was hypertensive and died of myocardial infarction.
Socio-Economic History
Computer engineer with an affluent family background
General Physical Examination:
A well-built middle aged man with severe chest pain, well oriented in time, space and
person.
Cardiovascular Examination:
Pulse: 98/min
BP: 145/105 mm Hg.
O2 saturation: 95% on room air.
ECG showed ST elevation in lead V1-V4.
On subsequent testing Trop I and CKMB was raised.
Respiratory Examination:
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Chest is normal shape and expansion. On palpation chest movement is bilaterally equal
with normal tactile fremitus. On auscultation there is normal vesicular breathing.
GIT:
Abdomen soft, non-tender. Spleen is just palpable below the left costal margin. It is firm
and tender. There is no evidence of free fluid in abdominal cavity. Bowl sounds are
audible.
CNS: No cognitive, sensory, motor or movement abnormality.

LEARNING OBJECTIVES
Knowledge
The student should be able to:

1. Relate the pathogenesis of cell injury with its morphology. **

2. Describe the pathogenesis and morphology of necrosis and apoptosis.**
3. Relate the pathogenesis of infarction with its morphology.*
4. Discuss epidemiology, prevention & control of cardiovascular diseases. **
5. Enumerate the intracellular accumulations and correlate their histology with
pathogenesis.**
6. Diagnose a case of Ischemic heart disease based on clinical presentation and
investigations.*
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7. Order and interpret laboratory tests for Acute Coronary Syndrome (ACS).**
8. Formulate an evidence-based management plan for Acute Coronary Syndrome.**
9. Describe the mechanism of action, pharmacokinetics, adverse effects,
contraindications and possible interactions of the drugs used in Angina and
Myocardial Infarction.**
10. Formulate research objectives and operational definitions.**
11. Understand literature search.**

SKILLS

The student should be able to:

1. Identify histopathological features of necrosis on microscopy.*
2. Identify features of necrosis on gross examination of histopathological
specimen.*
3. Identify intracellular accumulations e.g. fatty change, hemosiderosis,
cholestasis, melanosis, anthracosis and dystrophic calcification under the
microscope.*
4. Perform precordial examination.*
5. Interpret ECG changes in a patient with angina and myocardial infarction.*

CRITICAL QUESTIONS
 What is the most likely cause of his symptoms?
 What is the pathogenesis in a cell following injury?
 What morphological changes occur in an injured cell following insults like
ischemia, free radical injury, bacteria and toxins?
 What basic investigations are done in acute coronary syndrome?
 What management strategy is followed in these patients?
 What intracellular accumulations are acquired in a cell subjected to sub
lethal chronic injurious stimuli?
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THEME 2: A PATIENT IN SHOCK

VIGNETTE 1:
A 24 year-old man sustained multiple injuries in a road traffic accident. He was shifted to
the emergency department of a hospital. On examination, he was conscious but drowsy.
His skin was cold and clammy and he appeared pale. He was afebrile, his pulse was
106/min, rapid and weak, BP was 70/40 mmHg, respiratory rate was 24/min and oxygen
saturation was 95%. Systemic examination was unremarkable. He had multiple lacerated
wounds and fracture of shaft of left femur. Intravenous line was established immediately
and blood was sent for cross-match.

VIGNETTE 2:
A 44 year-old truck driver presented with 2-day history of severe diarrhoea and vomiting.
He had passed more than 20 watery stools in the last 48 hours. On examination, he was
semiconscious and his skin was cool and moist. He was afebrile, his pulse was 112/min,
rapid and weak, BP was 75/50 mmHg and respiratory rate was 22/min. Systemic
examination was unremarkable. Intravenous fluids were immediately started and his stool
specimen, which had ‘rice water’ appearance, was sent to the laboratory for examination.

VIGNETTE 3:
A 46 year-old banker, a known case of non-insulin dependant diabetes mellitus, was
brought to the emergency department with 7-hour history of central chest pain, dyspnoea
and nausea. The pain radiated towards the left shoulder and was aggravated by exertion.
On examination, he was an obese man, conscious and well-oriented. His skin was cool
and moist. He was afebrile, his pulse was 112/min, rapid and irregular, BP was 80/50
mmHg and respiratory rate was 22/min. On chest auscultation, crackles were heard in the
basal regions of both lungs. His oxygen saturation was 94%. ECG showed ST elevation
and Q waves in leads V1-V6, and ST elevation in leads I & avL, while his cardiac
enzymes were raised.

VIGNETTE 4:
A 66 year-old man suffering from cirrhosis of liver underwent liver transplantation. 24
hours post-operatively, while still on ventilator, he developed fever. His skin was hot and
dry, temperature was 1020F, pulse was 132/min and BP was 70/40 mmHg. Systemic
examination was unremarkable. His oxygen saturation was 95% and urinary output was
12 ml/hour. Blood specimen was immediately sent to the lab for Gram staining, which
showed Gram negative bacilli.
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VIGNETTE 5:
A 16 year-old boy was stung by a bee on the left hand. Half an hour later, he felt nausea,
dizziness and difficulty in breathing. He was brought to the emergency department. On
examination, he appeared drowsy, was afebrile, his pulse was 112/min, BP was 70/50
mmHg and respiratory rate was 30/min. Skin was flushed and urticaria was present on the
trunk. There was swelling and redness on the dorsum of left hand. Chest examination
revealed bilateral wheezing. Intravenous line was established and normal saline infusion
was started and he was administered adrenaline, methylprednisolone and
diphenhydramine. The patient’s condition improved rapidly.

VIGNETTE 6:
A 29 year-old woman with no medical history of significance was brought to the
emergency room after a road traffic accident. On examination, she was fully conscious
and her skin was cold and clammy. Her temperature was 98.60F, pulse was 44/min, BP
was 60/30 mmHg and respiratory rate was 30/min. Chest and cardiac examination
showed no abnormality. Neurological examination revealed a Glasgow coma score of
15/15. Motor system examination revealed upper limbs weakness grade 1/5 and lower
limbs weakness grade 0/5 associated with atonia and areflexia. Sensory system
examination revealed absent sensations in all four limbs and the patient was incontinent
to urine and stool. There was no evidence of external or internal bleeding, tension
pneumothorax or massive pleural effusion and no orthopedic fractures.

VIGNETTE 7:
ELECTROCUTION
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A middle-aged goldsmith was living with a family of 3 sisters and a mother. His dead
body was brought for forensic autopsy by the police on a December morning with a
history of accidental fall on electric heater.

External examination showed the following findings

Middle aged person, good height, heavy physique

2 circular electric marks on the chest just above nipples

These marks were irregular

NO burn/tear marks on his clothes were found corresponding to the given history

On examination of routine viscera presence of ‘DIAZEPAM’ was reported

LEARNING OBJECTIVES
Knowledge

The student should be able to:

1. Differentiate between different types of shock on the basis of clinical
presentation.*
2. Describe the pathogenesis of different types of shock.*
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3. Describe ante mortem/postmortem injuries in an electrocution case.*

4. Differentiate between natural and unnatural death.*
5. Identify evidence of electrocution injury.*

THEME 3: A LADY WITH HEADACHE AND PALPITATIONS

Presenting Complaints:
Headache for one month
Palpitations for one month

History of Presenting Complaints:

A 50-year-old housewife has presented with headache and palpitations for the past one
month.
Past History
Not significant
Family History
Her father and elder brother have high blood pressure.
Socio-Economic History
Housewife with sedentary life style.
General Physical Examination:
A middle aged woman who is well oriented in time, space and person.
Vital Signs:
Temperature: 98.60 F
Pulse: 80/min
Blood pressure is 170/110 mm Hg
Respiratory rate: 18/min

Cardiovascular Examination:
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Heart auscultation: S1+S2+0

Respiratory Examination: Chest is normal shape and expansion. On palpation chest

movement is bilaterally equal.
GIT: Abdomen soft, non-tender. There is no evidence of free fluid in abdominal cavity.
Bowl sounds are audible.
CNS: No cognitive, sensory, motor or movement abnormality.

Laboratory investigations:

Lipid profile:
Serum Cholesterol: 250 mg/dl (<200)
Serum Triglyceride: 300 mg/dl (<160)
LDL Cholesterol: 155 mg/dl (<100)
HDL Cholesterol: 30 mg/dl (>45)

LEARNING OBJECTIVES
Knowledge
The student should be able to:

1. Draw a map of pathophysiological pathways leading to hypertension.*

2. Describe the pathogenesis and morphology of atherosclerosis.*
3. Relate the morphology of vascular aneurysms with their clinical
consequences.**
4. Identify the effects of hypertension on blood vessels.*
5. Describe the pathogenesis & consequences of raised plasma lipids.*
6. Discuss the lifestyle modifications for prevention of cardiovascular diseases.**
7. Interpret the pharmacology of anti-hyperlipidemia drugs through package
inserts.**
8. Describe mechanism of action, pharmacokinetics, adverse effects,
contraindications and possible interactions of the lipid lowering drugs and
concept of poly pharmacy of these drugs.**
9. Classify and select anti-hypertensive drugs and discuss the dosage,
pharmacokinetics, mechanism of action, adverse effects and drug interaction of
various anti-hypertensive agents.**
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10. Apply Vancouver style of referencing.**

11. Develop a research questionnaire.**
12. Understand methodology in research.**

SKILL

1. Identify histopathological features of atherosclerosis under the microscope.*

2. Make presentations on levels of prevention of Non communicable diseases.*

CRITICAL QUESTIONS
 What is the pathogenesis of hypertension?
 What end-organ damage is caused by hypertension?
 What are the investigations to be done in a hypertensive patient?
 During his follow up appointment 1 year later, his BP readings are above 145/90
mmHg.
What anti-hypertensive you will start.
 What non-pharmacological measures you will advise to this patient?
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THEME 4: A CASE OF BREATHLESSNESS AND ANKLE

SWELLING
Vignette
A 58 years old hypertensive man presents with dyspnea and dry cough that has been
progressively worsening over the last 6 months. Initially he experienced dyspnea only
after exertion. He now has dyspnea climbing up a few flight of stairs. On lying down, his
symptoms 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. The liver edge is tender and is 4cm below costal margin (tender
hepatomegaly). He has a marked peripheral edema. BP is 170/100 mmHg and pulse is
80/min, regular.

LEARNING OBJECTIVES
Knowledge
The student should be able to:

1. Outline the hemodynamic changes leading to edema, hyperemia and congestion

of tissue. **
2. Relate the pathophysiology of congestive cardiac failure with its clinical
presentation.**
3. Formulate a management plan for congestive cardiac failure.**
4. Identify the etiology of pericarditis and correlate its pathogenesis with
morphology.**
5. Identify the etiology of cardiomyopathy and correlate its pathogenesis with
morphology.**
SKILL
1. Identify edema and congestion on histopathological section.*

CRITICAL QUESTIONS
1. What are the most important causes of congestive cardiac failure?
2. What is pathophysiology of edema formation?
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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: A LADY WITH SWOLLEN LOWER LIMB

CASE:

Presenting Complaints:
• Pain and swelling in left calf—10 hours
• Breathlessness—1 hour
History of Presenting Complaints:
A 55 year old lady who is a post-op case of fracture left ischial spine of pelvic bone and
was operated 2 weeks back. She is on bed rest and she has developed pain and swelling in
left calf for the last 10 hours. Her symptoms are now aggravated with shortness of breath.

Past History: Post-op case of fracture left ischial spine of pelvic bone.

Drug History: Not significant.

Family History: Father died due to pulmonary embolism

Socio-Economic History: Not significant

GENERAL PHYSICAL EXAMINATION:
A middle aged woman well built; conscious and well-oriented but looking anxious.
Vital Signs:
Temperature: 98.60 F
Pulse: 90/min
BP: 140/100 mmHg
Respiratory Rate: 18/min
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SYSTEMIC EXAMINATION:
CVS: Left calf is swollen,
Left ankle joint shows pitting edema.
On examination her left calf is erythematous, warm, tender and 4 cm thicker than the
right calf.

Respiratory System: Chest is normal in shape & expansion. On auscultation, there are
bilateral basal crepitations.
GIT: Abdomen soft, non-tender. There is no evidence of free fluid in the abdominal
cavity. Bowel sounds are audible.
CNS:
No cognitive, sensory, motor or movement abnormality.

PBL (Thromboembolism)*
LEARNING OBJECTIVES
Knowledge
The student should be able to:

1) Outline the salient features of hemostasis in the human body.*

2) Correlate the pathogenesis of thrombosis with its clinical presentation.*
3) Differentiate between ante and post mortem clot.*
4) Enumerate the types of embolism and discuss their pathophysiology.*

5) Relate the pathogenesis of vasculitis with its clinical presentation.**

6) Describe the disorders of blood vessel hyperreactivity (Raynaud’s, varicose veins,
thrombophlebitis).**
7) Classify vascular and heart tumors describing their morphology.**
8) Describe the dosage, pharmacokinetics, mechanism of action, adverse effects,
drug interactions & contraindications of the drugs used in the management of
deep vein thrombosis.**
9) Enlist different types of diuretics and describe their mechanism of actions and
adverse effects.**
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SKILL
The student should be able to;
1. Order appropriate tests to diagnose DVT.**
2. Identify vascular thrombosis under a microscope.*
3. Identify morphological features of myxoma under the microscope.*
4. Identify capillary and cavernous heamangioma under microscopy.*
5. Prescribe a management plan for DVT treatment.*

CRITICAL QUESTIONS
 What are the risk factors for DVT?
 What is the underlying pathogenesis for thrombosis?
 What is the fate of thrombus?
 How will you manage a patient with DVT?
 What are the different types of emboli?
 Which thrombolytic agent should this patient receive?

THEME 6- A MAN WITH PALPITATIONS AND SYNCOPE

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VIGNETTE:

A 76-year-old man presents with a week-long history of intermittent palpitations. He is

currently asymptomatic. He has history of hypertension that is treated with
hydrochlorthiazide and lisinopril.
On general physical examination he is alert and oriented. His heart rate is 120/min,
pulse is irregular and blood pressure is 130/80 mmHg.
ECG revealed irregular rhythm with no identification, wavy base line and normal P
waves.

LEARNING OBJECTIVES
Knowledge
The student should be able to:
1. Classify anti arrhythmic drugs on the basis of their clinical use and mechanism of
action.**
2. Describe indication of anti-arrhythmic drugs, organ system effects,
pharmacokinetics, adverse effects, interactions and contraindications.**

CRITICAL QUESTIONS
 What is the most likely diagnosis?
 How you will manage a patient with atrial fibrillation?
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THEME 7: A YOUNG MAN WITH FEVER AND HEART MURMUR

CASE 1 :

CASE:
Presenting Complaint:
• Low-grade fever 3 weeks
• Loss of appetite 3 weeks
• Malaise 3 weeks
• Arthralgia 2 weeks

History of Presenting Complaints:

Patient was in usual state of health three weeks back when he developed low-grade
persistent fever and malaise. His appetite is poor. He also complains of easy fatigability
and fleeting pain and swelling in joints. There is no history of sore throat, urinary or chest
complaints, or diarrhea.

Past History: No significant medical and surgical past history

Drug History: Known case of intravenous drug abuse for the last 7 years.
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Family History: Not significant.

Socio-Economic History: Belongs to a poor background. He is unemployed and

dependent on family members for support.

GENERAL PHYSICAL EXAMINATION:

A young man of thin built; conscious and well-oriented but toxic looking. Conjunctival
petechiae are present in both eyes. Splinter haemorrhages are seen under the nails of
hands. There are numerous injection marks on both forearms. No evidence of jaundice or
any lymphadenopathy.
Vital Signs:
Temperature: 1010 F
Pulse: 102/min
BP: 110/70 mmHg
Respiratory Rate: 18/min

SYSTEMIC EXAMINATION:
CVS: A 1/6 blowing murmur is heard best at the left lower sternal border that increases
with inspiration and decreases with expiration.
Respiratory System: Chest is normal in shape & expansion. On palpation, chest
movement is bilaterally equal with normal tactile fremitus. On auscultation, there is
bilateral normal vesicular breathing.
GIT: Abdomen soft, non-tender. Spleen is palpable 3 cm below the left costal margin. It
is firm and tender. There is no evidence of free fluid in the abdominal cavity. Bowel
sounds are audible.
CNS:
No cognitive, sensory, motor or movement abnormality.

CASE 2 :
Case history
An 11 year old boy presents with fever, pain and swelling in multiple joints along
with shortness of breath for 4 days. Two days ago, his right knee was painful and
swollen, but today it has improved, while the right ankle and left knee are quite
tender, painful and also swollen. On examination he has tachycardia with a
holosystolic murmur 3/6 heard at apex with radiation to axilla. His left knee is
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swollen and extremely tender with warmth. He has past history of acute tonsillitis
3 weeks back. His lab investigations show:

LEARNING OBJECTIVES
Knowledge
The student should be able to:

1. Correlate the etiology and pathogenesis of Infective Endocarditis with clinical

presentation.*
2. Describe morphology and pathogenicity of Staphylococcus and correlate it with
different infections caused by the microorganism.*
3. Classify bacterial toxins and describe their role in disease process.*
4. Outline the principles of management of a patient of Infective Endocarditis.*
5. Describe the pathogenesis, clinical presentation and diagnosis of Rheumatic fever
and Rheumatic Heart Disease.**
6. Classify cell wall synthesis inhibitors. **
7. Describe the mechanism of action, pharmacokinetics, clinical indications, adverse
effects and possible interactions of cell wall synthesis inhibitors.**
8. Describe treatment (immediate & long term) & prophylaxis of Rheumatic fever
and Rheumatic Heart Disease.*

CRITICAL QUESTIONS

 What are the important physical findings of infective endocarditis?

 What causative organisms are most likely in this patient?
 What are major and minor criteria for diagnosis of infective endocarditis?
 What is the etiology, pathogenesis and complications of rheumatic fever?
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THEME 8: A CASE OF SUDDEN DEATH

Case 1:

CHANGES AFTER DEATH

An unknown adult dead body was brought by the police during the month of JULY.
Police requested for forensic autopsy with query of his identification and cause of death
(natural or unnatural).

On external examination whole of the dead body was distended, foul smelling, had
multiple blebs, skin slip, marbling on upper chest and both thighs. Facial features were
disfigured with protruding tongue and both eyeballs were bulging out from sockets.
There was presence of multiple blue bottle flies and clothes were wet and greasy.

There was an entry wound on right parietal region. No wound of exit was found.

Methods for identification used were: Age assessment, blood grouping, analysis of
belongings, fingerprinting along with X-ray skull, neck and chest.

Bullet fragments were found on mid-cervical region left side. Left tibial deformity was
found.

LEARNING OBJECTIVES
Knowledge
The student should be able to:
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1. Estimate time since death.**

2. Identify an unknown dead body.*
3. Identify radiological modalities assisting in identification of an unknown dead
body.*
4. Discuss the importance of belongings in identity.**
5. Identify changes after death relative to time line.**
6. Discuss the concept of negative autopsy.**

Case 2:

Nerium Oleander
A 21-year-old female was admitted in the emergency room with vomiting and
lightheadedness 15 hours after ingestion of common oleander aqueous leaf extract (10-20
leaves). She had been advised to take the extract in order to conceive a baby. She was a
non-smoker and non-alcoholic, no drugs allergy and was mentally sound.

On initial examination, the blood pressure was 122/80 mmHg with irregular pulse of
46/min. She was looking toxic due to excessive vomiting. Other general physical
parameters were normal. Her chest and lungs were clear to auscultation and percussion.
Cardiovascular examination revealed an irregular rhythm with soft S1and normal audible
S2 over the cardiac apex.

Electrocardiogram revealed inverted P wave in inferior lead and prolonged PR interval

with varying degree AV blocks and normal QRS duration.
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She was given .6 mg of intravenous atropine sulfate which did not resolve her
bradycardia, but other symptoms were improved. Next day, the patient was given
intravenous atropine sulfate.6 mg twice a day. After three days, the patient was
discharged on request being asymptomatic.

Case 3:
SUDDEN and UNEXPECTED DEATH

A 56-year-old businessman was staying in a hotel during his business trip to Islamabad.
He was healthy and had no medical complaints. He took his dinner late at night and went
to bed.

The next morning at 11.30am his bedroom door was forcefully opened where he was
found dead. The body was brought to the medicolegal officer for forensic autopsy.

On external examination there were no signs of struggle or violence on the body.

Hypostasis was developed on the back with contact flattening on shoulders back and
buttocks. Rigor mortis was partially developed in the upper limbs.

On internal examination Heamopericardium was found with rupture of left ventricle.

Rests of the viscera were unremarkable. Routine viscera and body fluids sent for
chemical examination reported no poison.

LEARNING OBJECTIVES
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Knowledge
The student should be able to:

1. Define death.**
2. Confirm and declare death.**
3. Estimate time since death from the analysis of changes after death.**
4. Differentiate between natural and unnatural death.**
5. Discuss the concept of forensic autopsy and its method.**
6. Identify the poisons that can lead to a cardiac event.**

7. Explain and comprehend HMIS, DEWS and IDSR.**

8. Measure associations and their calculations.**
9. Design and pilot a consent form.*

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
• What methods would you imply in determining the time since death?
• What are the different biochemical and morphological changes seen in different
organs after death?
• What are the WHO criteria of certification of death
• How would you ascertain the mode, manner, mechanism and cause of death on
the postmortem examination?

CRITICAL QUESTIONS

 What are 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?
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 How would you calculate the time since death after reviewing the changes
after death?

Recommended Reference Books:

 Medicine:
• Kumar and Clark clinical medicine
• Davidson’s principles and practice of Medicine
• Current medical diagnosis and treatment
 Pathology: Robbins Pathologic Basis of Disease
 Microbiology: Levinsons Review of Medical Microbiology and Immunology
 Pharmacology:
• Basic & Clinical Pharmacology Bertram G. Katzung
• Lippincott’s Pharmacology
• Essentials of medical pharmacology, JayPee, Tripathy
 Forensic:
• Parikh’s Textbook of medical Jurisprudence.
• Krishan VIJ Textbook of Forensic Medicine & Toxicology.