Outcomes - COMPAS

Modules

Year 2 CR2: Cardiorespiratory 2

Dr Julian Millar
j.millar@qmul.ac.uk

Introduction

By the end of the course the student should understand

1) The structure and function of the heart in terms of how it relates to generating and maintaining cardiac output. The causes and major consequences of valvular heart disease. How electrical activity in the heart is initiated, how it is transmitted, and how it acts to produce efficient synchronised pumping. How to interpret a 12 lead ECG and do a rhythm analysis and a simple conduction analysis.

2) The anatomy and physiology of blood vessels, in particular the role of the endothelium of blood vessels.

3) The physiological mechanisms involved in the homeostasis of blood pressure and blood volume. The effects of hypertension, hypotension & haemorrhage.

4) The condition of clinical shock and how it may be managed

5) The common signs and causes of myocardial infarction.

6) Standard drug treatments for cardiovascular illness.

7) The anatomy and physiology of normal lungs and lung function. How lung function may be investigated; The nature of restrictive and obstructive lung diseases, and the consequences of each of these conditions.

8) Respiratory homeostasis of blood gases and pH and how these functions may be compromised in disease.

9) The signs and symptoms of lung cancer & tuberculosis, and the management of these conditions.

10) The common disorders of blood function including the anaemias and leukaemias

Sessions

Lecture: Erythropoiesis & Anaemia
1. Iron absorption
2. Sites and stages of Erythropoiesis
3. RBC count
4. Removal and recycling of senescent red cells
5. Causes of iron deficiency anaemia
6. Classification of anaemias based on RBC size
7. Distinguishing between different types of iron deficiency anaemia
Lecture: Cardiovascular Clinical Skills
Teaching Material for this Session
1. You should be confident in locating (via anatomical landmarks) and commenting on the strength of the following pulses:radial, brachial, carotid, popliteal, dorsalis pedis, posterior tibial
2. Identify the organs of the upper respiratory system
3. Describe the structure, function and interconnections of the nose, paranasal sinuses and pharynx
4. Describe the structure of the larynx, and discuss its roles in normal breathing and in the production of sound
5. Explain the nervous innervations to the pharynx and larynx
6. Describe the rate and rhythm of the radial and carotid pulses
7. Take blood pressure competently on a normal person by first estimating the systolic pressure by palpation and then accurately measuring by auscultation
8. Recognise the pulsation of the normal JVP and assess its vertical height above the manubrio-sternal angle
9. Know the surface markings of the heart (including apex and valves) and main vessels
10. Accurately locate the normal apex beat, and report on its location by standard anatomical landmarks
11. Auscultate the normal heart and time the heart sounds with the pulse in your assessment of the cardiac cycle
12. Know the four main areas to auscultate, and know how to use the Bell and Diaphragm of the stethoscope
13. Recognise the first and second heart sounds, the systolic and diastolic spaces, by timing the cardiac cycle against a central pulse
14. Put together your assessment of the pulse, peripheral pulses, blood pressure and cardiac examination to form an examination of the cardiovascular system
15. Understand the 12 lead ECG, including lead placement and general principles behind what it assesses
Lecture: Development of Heart
Teaching Material for this Session
1. Understand the basic development of the heart
2. Describe how foetal circulation differs from that of neonate
3. Understand the circulatory adaptations at birth
4. Describe some common congenital abnormalities of the heart
Lecture: Introduction to Medicine in Society
1. Outline the Aims and Objectives of the Medicine in Society 2 and EPC Course
2. Identify constructive feedback.
3. Recognise how to act professionally on clinical placements.
4. Describe the assessment criteria for this unit.
Lecture: Macrocytic Anaemia
1. Causes of macrocytic anaemia
2. Vitamin B12 and folate functions
3. Features of B12 and folate deficiency
4. Anaemias caused by decreased RBC lifespan (haemolytic)
5. Evaluation of suspected haemolytic anaemia
Lecture: Applied Anatomy of the Heart
Teaching Material for this Session
1. Surface anatomy of the heart
2. Describe the nervous innervation of the heart and explain the anatomical basis of cardiac referred pain.
3. Describe the anatomy and distribution of the coronary circulation.
4. List some common causes of remodelling.
Lecture: Haemostasis Basics
1. To be aware of the categories of drug which may be used for therapeutic purposes to modify haemostasis.
2. To appreciate, in broad terms, the way in which problems may arise as a result of inherited or acquired pathology.
3. To be able to relate these elements to the essential functions of the control of bleeding and the prevention of thrombosis .
4. To understand the key elements of the haemostatic mechanism.
Lecture: ECG Review
1. Using this protocol recognise the following:
2. Describe a standard protocol for ECG analysis
3. Describe key measurements in initial ECG analysis
4. Normal sinus rhythm, sinus bradycardia, sinus tachycardia
5. Ventricular tachycardia, Ventricular fibrillation,
6. Atrial fibrillation, Atrial flutter, Junctional rhythm, Supraventricular tachycardia, Bundle branch block, ST elevation and depression,
7. Describe a method for determining the electrical axis of the heart
8. First, second and third degree heart block,
Lecture: Haemostasis and Thrombosis
1. Understand normal coagulation.
2. Understand the main disorders that lead to excess bleeding or clotting and how they are treated.
3. Understand the clotting cascade and how it is monitored in the laboratory.
4. Understand platelet function and reasons for platelet dysfunction.
Lecture: Angina
Teaching Material for this Session
1. Distinguish between the terms chronic stable angina and acute coronary syndrome
2. Explain what determines O2 demand and supply in the heart (cardiac economics)
3. Illustrate how treatment alters this O2 balance
4. List the priorities in the management of a person with angina
5. Plan how to improve their own skills in diagnosing & managing a person with angina
Lecture: Athersclerosis and Coronary Artery Disease
Teaching Material for this Session
1. Describe the development of atherosclerosis
2. Recognise the complications of atherosclerosis
3. Describe the clinical symptoms and signs of coronary artery disease and their association with underlying pathology.
4. Describe the prevention and treatment strategies for coronary artery disease, with particular attention paid to the mechanism of action of drugs.
Lecture: Anatomy of the Thorax
Teaching Material for this Session
1. Surface anatomy
2. Revise anatomy of the thoracic wall and understand the clinical relevance.
3. Understand the functional anatomy and nerve supply of the pleura
4. Understand some simple lung pathologies
Lecture: Hypertension
Teaching Material for this Session
1. Define hypotension, hypertension & postural hypotension
2. Understand epidemiology of hypertension - national and global perspectives
3. Describe the normal control of blood pressure and how it may go wrong in hypertension
4. Explain the extra risks of hypertension in diabetics and obese individuals
5. Describe the pathophysiology of hypertension
6. List the main non-pharmacological and pharmacological therapeutic strategies to manage hypertension
Lecture: Venous Thromboembolism
Teaching Material for this Session
1. Describe the pathological and physiological mechanisms leading to DVT and pulmonary embolism.
2. Discuss the causes and predisposing factors of DVT and pulmonary embolism.
3. Describe the presentation and diagnosis of DVT and pulmonary embolism.
4. Describe the relationship between DVT and pulmonary embolism.
5. Discuss the treatment of DVT and pulmonary embolism and the prognosis in both conditions.
6. Be aware of the newer anti-thrombotic agents e.g. fondaparinux, direct thrombin inhibitors, antiplatelet drugs and thrombolytic agents
Lecture: Respiratory Failure
Teaching Material for this Session
1. To understand what pathophysiological processes affect this oxygen cascade.
2. To understand how oxygen passes from the atmosphere to the arterial level.
3. To understand treatment options in respiratory failure.
4. To identify symptoms and signs of respiratory failure.
Lecture: Respiratory Clinical Skills
Teaching Material for this Session
1. Use the correct technique of measuring peak flow in a normal subject
2. Know the surface markings of the normal lungs
3. Auscultate the lungs and recognise normal breath sounds
4. Put together examination of the hands, pulse, JVP and lungs to conduct a systematic examination of the normal respiratory system
Lecture: Clinical Anatomy of the Larynx
Teaching Material for this Session
1. Neck surface and functional anatomy
2. Emergency airways
3. Sinuses and their interconnections
4. Blood supply to the head and neck
5. Innervation of the larynx
6. Mouth, lymphoid tissue, and the pharynx
7. Larynx
Lecture: Cardiomyopathies
1. Understand what is meant by the term cardiomyopathy and how the condition is classified.
2. List the major subtypes of cardiomyopathy.
3. Describe the three major forms of cardiomyopathy (DCM, HCM & RCM) in terms of their etiology/causes, signs/symptoms, pathology/pathophysiology, diagnosis and treatment.
4. Recognise other forms of myopathy e.g. Arrhythmogenic right ventricular cardiomyopathy (ARVC).
Lecture: White Blood Cells and the Innate Immune System
1. Describe the lineage and morphology of granulated leucocytes (neutrophils, basophils, eosinophils, mast cells and monocytes).
2. Describe their role in the immune system defense against pathogens
3. Understand the role of antigen presenting cells (APCs) in the immune response
4. Understand the role of Natural Killer Cells in the immune response
5. Briefly describe the role of the immune system in asthma
Lecture: Obstructive Lung Diseases
Teaching Material for this Session
1. Describe the pathological mechanisms that underpin asthma and COPD
2. Describe clinical symptoms and signs that are associated with asthma and COPD
3. Explain the importance of lung function testing, especially spirometry, in the diagnosis of asthma and COPD
4. Discuss pharmacological treatments for asthma and COPD
Lecture: Restrictive Lung Disease
Teaching Material for this Session
1. Describe the pathological mechanisms that drive restrictive lung diseases.
2. Describe clinical symptoms and signs that are associated with restrictive lung diseases.
3. Explain the importance of lung function testing, especially spirometry, in the diagnosis of restrictive lung diseases.
4. Describe the common categories of restrictive lung diseases.
5. Discuss pharmacological treatments for restrictive lung diseases.
Lecture: Type 1 Hypersensitivity and Anaphylaxis
Teaching Material for this Session
1. Shock revisited.
2. Revise immunology: Innate versus adaptive; Tolerance & memory; B lymphocytes versus T-Lymphocytes.
3. Activation of mast cells.
4. Type 1 hypersensitivity revised, atopy revised.
5. Anaphylactic shock: initiation, diagnosis, differential diagnosis.
6. Treatment & prevention of anaphylactic & anaphylactoid shock.
Lecture: Upper Respiratory Tract Infection
Teaching Material for this Session
1. Describe the common causes and types of upper respiratory tract infections.
2. Describe the underlying pathology in upper respiratory tract infections.
3. Understand the effect of viruses on pre-existing respiratory conditions.
4. Describe clinical symptoms and signs that are associated with upper respiratory tract infections.
5. Describe the main therapeutic interventions to treat upper respiratory infections.
Lecture: Lower Respiratory Tract Infections
Teaching Material for this Session
1. Describe the main causes of lower respiratory tract infections
2. Explain how to diagnose and treat lower respiratory tract infections
3. Discuss the importance of lower respiratory tract infections as a cause of morbidity and mortality both in the hospital and community setting
Lecture: Respiratory Function Tests
Teaching Material for this Session
1. Understand the limitations of current tests and how the technique of performing the tests may affect the results, with understanding of how individuals are compared to equivalent populations.
2. Understand the abnormalities seen in asthma and COPD where there is an obstructive defect, and the patterns of obstruction and restriction and their causes.
3. Describe the tests for gas transfer and their limitations and value, especially in interstitial lung disease.
4. Discuss other tests of respiratory function including exercise testing and their use in assessing operative risk.
Lecture: Myocardial Infarction
Teaching Material for this Session
1. Pathophysiological mechanisms of infarction as the basis for logical treatment.
2. Diagnosis
3. Risk Stratification
4. Emergency Management
5. Outcomes
6. Secondary prevention
Lecture: Valvular Heart Disease
Teaching Material for this Session
1. Understand the anatomy and physiology of normal heart valves
2. Discuss the causes of aortic stenosis and regurgitation
3. Discuss the symptoms of aortic stenosis and regurgitation
4. Understand the management of the patient with aortic valve disease
5. Discuss the causes of mitral stenosis and regurgitation
6. Discuss the symptoms of mitral stenosis and regurgitation
7. Understand the management of the patient with mitral valve disease
8. Discuss briefly pulmonary and tricuspid valve disease
Lecture: Tuberculosis
Teaching Material for this Session
1. Describe important features of diagnosis, treatment and prevention of tuberculosis including vaccination.
2. Explain what is meant by Pulmonary Tuberculosis
3. List the clinical features of tuberculosis
4. Describe an elementary classification of mycobacteria
5. Understand the epidemiology and public health significance of tuberculosis.
6. State features of diagnosis and treatment of infections with other mycobacteria.
Lecture: Stroke
1. Types of stroke
2. Signs and symptoms
3. Epidemiology
4. Risk Factors
5. Role of sodium pump in nerve cells
6. Excitotoxicity
7. Concept of penumbra
8. Treatment
Lecture: Haemorrhage and Shock
Teaching Material for this Session
1. Define and classify shock
2. Describe physiology of normal tissue perfusion.
3. Describe short and long term mechanisms that allow compensation for haemorrhage.
4. Describe the clinical presentation of the different kinds of shock.
Lecture: Haemoglobinopathies
Teaching Material for this Session
1. Genetic basis of thalassaemia and sickle cell disease.
2. How these genetic alterations affect the normal physiology of haemoglobin and the red cell.
3. The clinical consequences.
4. The treatment of sickle cell disease and thalassaemia major.
5. Rationale and methodology for screening for haemoglobin disorders.
Lecture: Respiratory Acidosis and Alkalosis
1. Describe the signs, symptoms and causes of respiratory acidosis and alkadosis, and how they may be treated.
2. Explain the relationship between pCO2 and [HCO3-] as expressed in the Henderson-Hasselbalch equation.
3. Be able to interpret graphs showing the relationship between pCO2, [HCO3-] and pH
4. Understand the difference between type 1 and type 2 respiratory failure
Lecture: Lymphatics
Teaching Material for this Session
1. Describe the anatomy of blood and lymphatic vessels.
2. Explain how lymph is formed and returned to the bloodstream.
3. Describe the form and function of the lymph nodes, tonsils, thymus and spleen.
4. Discuss the lymphatic drainage of the body and the anatomy of the major lymphatic ducts.
Lecture: Heart Failure
Teaching Material for this Session
1. Pathophysiological mechanisms of heart failure
2. Diagnosis
3. Symptomatic management
4. Prognostic management
5. Outcomes
Lecture: Chest X-rays
1. Revise the bony thorax, the lungs, and the neuronal control of breathing
2. Understand the basic features of a normal chest X-ray
3. Understand the positions of the lobes of the lungs
4. Explain the functional anatomy of the pleurae
5. Understand the basic anatomical changes in some common lung pathologies and how they are identified in a chest X-ray
Lecture: Nitric Oxide in the Vascular System
Teaching Material for this Session
1. Explain the role of nitric oxide in the coronary and skeletal arterioles
2. Describe the properties of nitric oxide and its mechanism of synthesis in vascular endothelium
3. Describe the theory of nitric oxide function in the pulmonary circulation
4. Explain the role of nitric oxide in exercise
5. Understand the problem of the source of nitric oxide in exercising muscle
6. Understand the role if inducible nitric oxide synthase
Lecture: Exercise Physiology
Teaching Material for this Session
1. State how energy (in the form of ATP) is delivered to skeletal muscle during exercise.
2. Explain the cardiovascular adjustments made during exercise.
3. Describe changes to blood pressure during exercise.
4. Explain the respiratory adjustments made during exercise.
5. Define the term post exercise oxygen consumption.
6. Briefly describe how cardiac output and ventilation is matched to meet the metabolic demands of exercise.
Lecture: Physiology of High Altitude
Teaching Material for this Session
1. Explain the initial effects on the cardiorespiratory system by ascent to high altitude (2000-5000 m)
2. Explain what processes of acclimatisation can occur
3. Describe the signs and symptoms of acute mountain sickness (AMS)and how it may be treated
4. Explain how the kidney retrieves bicarbonate and sodium and explain why Acetazolamide (diamox) is an effective agent to treat AMS
5. Describe the signs and symptoms of HACE and HAPE and how they may be treated.
Lecture: Blood Groups and Transfusion
Teaching Material for this Session
1. Define blood group antigens and antibodies
2. Explain the difference between naturally occurring and immune antibodies
3. Describe the features of ABO and Rh blood group systems and explain how genotype relates to phenotype
4. Introduction to the pathogenesis of haemolytic disease of the foetus and newborn and discuss strategies for prevention
5. Interpret results of serological grouping tests and apply these to choice of components for transfusion
6. Describe the steps involved in organising a blood transfusion
7. Illustrate how antibody/ antigen interactions cause transfusion reactions
Lecture: Integrated Respiratory Clinical Cases
1. Calculate lung volumes, dead space and alveolar ventilation
2. Interpret chest x-rays of patients with and without respiratory diseases
3. Calculate respiratory gas exchange
4. Interpret lung volume and flow-volume curves/loops from healthy subjects and patients with respiratory disease (+/- post-treatment)
Anatomy Practical 1: Anatomy of the Heart & Common Pathologies
1. Revise the gross anatomy of the heart and the great vessels.
2. Relate myocardial infarction to the anatomy of the coronary circulation
3. Understand the efficacy of cardiac imaging techniques, e.g. echocardiography, coronary angiography.
4. Identify common locations for atherosclerotic lesions and the consequences of these.
5. Identify the basic features of a normal mediastinal silhouette and the basic features of cardiac pathologies in chest X-rays
6. Discuss and understand the pathological basis for atherosclerosis, myocardial infarction, mitral valve disease and aneurysm
7. Understand the basic development of the heart and common congenital abnormalities
Anatomy Practical 2: Thorax & Respiratory Disease
1. Revise the gross anatomy of the chest wall, the pleura, the lungs and bronchial tree
2. Describe the surface anatomy of the lungs and relate this to auscultation and percussion
3. Understand the extent of the pleural cavity and the consequences of pleural injuries
4. Review normal lung function tests and compare them with abnormal lung function tests from a patient with obstructive lung disease and restrictive lung disease
5. Identify the anatomical features of COPD, pneumonia, carcinoma and tuberculosis on pathological specimens and on radiographs
6. Describe a normal chest x-ray, and compare this with chest x-rays from patients with lung cancer, tuberculosis, Chronic Obstructive Pulmonary Disease and pneumothorax
Practical 1: Cardiovascular - Exercise
1. Discuss the changes that occur in the cardiorespiratory system during exercise, and how these may be compromised in cases of cardiorespiratory disease
Practical 2: The Control of Breathing
Microanatomy 1: Cardiovascular System
1. Describe the structure of heart valves
2. Discuss the structural changes that occur in valvular heart disease and how function is affected.
3. List the complications of myocardial infarction
4. List the causes of myocardial ischaemia and infarction.
5. Describe the changes in the coronary arteries that lead to myocardial ischaemia and infarction.
6. Describe the pathological changes that occur in a heart undergoing infarction
Microanatomy 2: Respiratory System
1. Recognise and describe specific disease processes that affect the lung, relating pathological features to radiological changes.
Microanatomy 3: Blood
1. Recognise abnormal features in blood films characteristic of white blood cell disorders.
2. Understand how the patient’s presentation, examination findings and other investigations including blood counts, complement microscopic analyses of blood films. Begin to interpret such information to form likely diagnoses in common conditions
3. Revise abnormal features in blood films characteristic of anaemias.
Clinical Skills 1: Cardiovascular Examination
1. Be confident in locating (via anatomical landmarks) and commenting on the strength of the following pulses: radial, brachial, carotid, popliteal, dorsalis pedis; posterior tibial
2. Be able to describe the rate and rhythm of the radial and carotid pulses
3. You should be able to take blood pressure competently on a normal person by first estimating the systolic pressure by palpation and then accurately measuring by auscultation.
4. You should be able to recognise the pulsation of the normal JVP and assess its vertical height above the manubrio-sternal angle.
5. Know the surface markings of the heart (including apex and valves) and main vessels.
6. You should be able to accurately locate the normal apex beat, and report on its location by standard anatomical landmarks.
7. You should be able to auscultate the normal heart, and time the heart sounds with the pulse in your assessment of the cardiac cycle.
8. You should be confident in recognising the first and second heart sounds, the systolic and diastolic spaces, by timing the cardiac cycle against a central pulse.
9. You should be aware of the four main areas to auscultate, and the use of the bell and diaphragm of the stethoscope.
10. You should be starting to put together your assessment of the pulse, peripheral pulses, blood pressure and cardiac examination to form an examination of the cardiovascular system.
11. You should have an understanding of the 12-lead ECG, including lead placement and general principles behind what it assesses.
Clinical Skills 2: Respiratory Examination
1. You should know the surface markings of the normal lungs.
2. You should be able to auscultate the lungs and recognise normal breath sounds.
3. You should be putting together examination of the hands, pulse, JVP and lungs to conduct a systematic examination of the normal respiratory system.

CR2 - PBL1: Three Tired Ladies

Teaching Material for this Session

Patient 1 was a 65 year old woman who presented with increasing tiredness and shortness of breath on exertion. On direct questioning, she was not taking any medication and had a normal mixed diet. During the past few months she had noticed a change in bowel habit with increasing constipation. On occasions, she had also noticed flecks of blood mixed with her stool. On examination she was pale and showed signs of atrophic glossitis and angular stomatitis. Her general practitioner arranged blood tests that included a blood count (see results table), blood film and investigations to confirm the diagnosis. Treatment was then discussed with the patient.

Patient 2 was a 74 year old woman who was referred by her general practitioner to the Accident and Emergency Department with pallor and difficulty in walking. For two months she had noticed increasing shortness of breath, and during the last month tingling in her hands and feet and unsteadiness. She was not taking any medication and had a normal mixed diet. On examination, she was mentally alert, pale, and mildly jaundiced. Her heart rate was 110 and her blood pressure was 135/85. Neurological examination revealed that she was unable to stand for more than a minute or so before she had to sit down. A blood count (see results table), blood film and investigations to confirm the reason for the patient’s symptoms were immediately arranged. Treatment with intramuscular hydroxocobalamin was commenced.

Patient 3 was a 49 year old woman who was having haemodialysis for management of chronic renal failure. She complained of exhaustion and palpitations after climbing upstairs in her house. A blood count (see results table) and blood film were reviewed prior to treatment.

Blood count results:

	Patient 1	Patient 2	Patient 3	Normal values
Haemoglobin (Hb)	8.2 g/dL	4.4 g/dL	5.3 g/dL	11.5 – 15.5 (f) 13.5 – 17.5 (m)
Mean Corpuscular Volume (MCV)	67 fL	119 fL	94 fL	80 – 96fL
White blood cell count	6.6 x109/L	2.9 x109/L	8.4 x109/L	4.0 – 11.0 x109/L
Platelet count	390 x109/L	59 x109/L	255 x109/L	150 – 400 x109/L
Reticulocytes	2.1%	2.5%	0.5%	0.5 – 2.5%
Blood film	Microcytic red cells	Macrocytic red cells, HSN*	Normocytic red cells

* Hypersegmented neutrophils present

CR2 - PBL2: Sharon Phillips
Teaching Material for this Session

Sharon Phillips, 19 years old, likes to go clubbing. A few weeks ago she slipped over on the dance floor and badly bruised her arm and knee. She has come to see you because the bruises are unsightly and taking a long time to fade. On questioning, she admits to having heavy periods and, as a child, having recurrent nose bleeds. She continues to have occasional nose bleeds that are a nuisance as they take a long time to stop. She admits to occasional binge drinking and some nasty hangovers. Her mother has been very supportive as she has also had heavy periods and says “it runs in the family”. You arrange for some blood tests and on the basis of the results suggest some options.

Blood test results:

HB: 11.2 g/dL (normal 11.5-15.5)

MCV: 82 fL (normal 80-96)

WBC: 7 x 109 /L (normal 4-11)

Platelets: 150 x 109/L (normal 150-400)

Routine Coagulation Tests:

PT: 12 s (normal 10-12)

APTT: 65 s (normal 26-40)

TT: 15 s (normal 15-19)

Special Coagulation Tests:

Factor VIII clotting assay: mildly reduced

Factor IX clotting assay: Normal

Von Willebrand Factor Antigen (VWF:AG): Reduced
CR2 - PBL3: Michael O’Conlan
Teaching Material for this Session

Michael O’Conlan is a 58 years old HGV driver. He recently moved house to a new home at the top of a moderately steep hill. He comes to his GP complaining that he gets breathlessness and pains in the chest whenever he has to walk up the hill from the shops. He does not report pains at other times. When she weighs him his GP finds a BMI of 33. Michael admits he gets very little exercise and spends most evenings in the pub or in front of the television. When asked about his diet he says that since his divorce he has lived mainly on chocolate bars and take-aways. He smokes ‘roll-ups’ and has done since age 15. A physical examination reveals some tachypnea at rest, and dyspnea that rapidly develops during mild exercise. The GP refers him to the local hospital for blood tests, and in the meantime writes him a prescription for some pills that he should place under his tongue when the arm pains occur. She informs Padraig that he may have a heart condition, but the medication should both relieve his symptoms and slow the rate of progression of his illness. When the tests come back they show C-reactive protein levels of 2.8 mg/litre but were otherwise normal.

He is referred to the local coronary care unit where his resting ECG is found to be normal. However, during an exercise ECG he feels the pain again and there is a change in his ECG which is diagnostic. During the test his heart rate and blood pressure both rise. He is prescribed aspirin (75 mg daily), a calcium-channel blocker and a statin. He is also given a spray which he can use whenever he feels the pain. The hospital consultant explains that further treatments are possible should his condition get worse. He is discharged and warned to avoid strenuous exercise and to try to stop smoking and lose some weight.

Michael tries but is unable to stop smoking or lose weight. Three months after his discharge from hospital he collapses in the street on his way to the local shops. An ambulance was called. The paramedics found him to be conscious but in great pain. He said it was like “his chest was being squeezed in a vice”. On arrival at A&E he was pale, sweating, nauseous and had vomited once in the ambulance.

An ECG showed pathological Q waves and ST segment elevation in leads II, III and aVF. He was given medication and after sedation a stent was inserted in a coronary artery. He was transferred to the coronary care unit. His evolving ECG and cardiac enzymes confirmed the diagnosis of myocardial infarction. After 5 days recovery in the CCU he was discharged with additional medication and an appointment to see his GP the following week.

At the appointment his G.P. carried out a physical examination and gave him some lifestyle advice, which he promised to follow.
CR2 - PBL4: Patricia Aledambo
Teaching Material for this Session

Patricia Aledambo is 36 years old and in general good health, although she has been overweight since her teens. She says her husband likes her that way and she has no plans to diet. However, she has stopped smoking now that she is pregnant with her second child. Two weeks ago she returned from a visit to her parents in South Africa. Her blood pressure was slightly raised at a routine ante-natal examination just after she returned, so she has been taking it easy and having plenty of bed rest since then. She visits her GP because of persisting pain in her left leg, which gets worse on standing or walking.

On examination her leg is found to be swollen, warm, and painful to palpation between the knee and ankle. There is pitting oedema in the swollen leg. The GP refers her urgently to the local A&E department. During examination in the A&E a Wells score was calculated at 3. A detailed history revealed that her mother had had a pulmonary embolus after Patricia had been born. She was given an injection and warned that she would need injections on a daily basis for the time being. She was then sent home after being booked in for her injection and further tests the next day.

One month after her visit to A&E Patricia comes back to the GP with new problems. Her leg seems to be much better, but she is having breathing problems. She reports that she has been wheezing a lot after going upstairs or trying to exercise. Breathing is sometimes becoming painful and she has also been sweating a lot and developed a troublesome cough. One time she coughed up a little blood. Last week while standing travelling on the tube she felt very faint and thought she would collapse. On examination the GP notes marked tachypnea (rr 20 /min) and tachycardia (hr 105) and on auscultation he detects lung crackles and a slightly accentuated second heart sound. She is now four months pregnant and wonders if her new symptoms have anything to do with her pregnancy and if her baby is ok.

The GP reassures her that her symptoms are unlikely to have affected the baby but says that her chest needs an urgent checkup and arranges for an ambulance to take her immediately to A&E for further tests.
CR2 - PBL5: Tracy Sinclair
Teaching Material for this Session

20-year-old Tracy is a new patient who attends your GP practice to discuss her worsening asthma. Struggling to speak, she says she moved into the area about 2 months ago. She admits her accommodation is in a poorly maintained building that is damp, but hopes to move. She has a history of asthma from childhood and is a smoker of 10 cigarettes per day. Tracy has woken up 3-4 times a night for the last 2 weeks or so gasping for air, and has had difficulty ‘catching her breath’. Her attacks are controlled by using the ‘blue puffer’ given to Tracy by her last GP, which “‘provides some immediate relief and is great’. But she is using the inhaler during the day every day plus at night. Past medical history reveals several previous exacerbations requiring one hospitalization in the last year. She states she is not allergic to any medications, but has occasional eczema.

She admits her adherence to her preventer inhaler is poor and her failure to attend annual asthma reviews. Examining her, you note Tracy is breathless at rest, with a respiratory rate of 26 breaths per minute. She is wheezing audibly, particularly on exhalation. There is an extended forced expiratory phase to her breathing cycle. Auscultation revealed bilateral diminished breath sounds, bilateral expiratory wheezing and use of her accessory muscles of ventilation. Her blood pressure is 155/85 mmHg and heart rate 115 beats per minute. Tests in the surgery show that peak expiratory flow (PEF) rate is 40% of the predicted normal range. A pulse oximeter gives a value of 92%.

She is treated in the surgery with oxygen and a nebulized Beta2-agonist, and then admitted to hospital. On hospital admission, her blood pressure is 160/87 mmHg, heart rate 120 beats per minute, respiratory rate 26 breaths per minute and oxygen saturation measured by pulse oximetry of 92% on room air. Immediately, she is given controlled supplementary oxygen to maintain an SpO2 level between 94-98%.

She is administered regular nebulised salbutamol by wet nebulisation driven by oxygen. She has regular peak flow measurements. Her blood gases on arrival show:

pH                   7.43

PCO2             5.1KPa

PO2                8.3KPa

Post oxygen therapy, her SaO2 rises to 95% within 3 hours. Within 12 hours, her symptoms have subsided and she is feeling much better. Her audible wheezing is completely resolved and her peak expiratory flow rises to 80% predicted. She is transferred from nebulisers to inhaled salbutamol, started on inhaled steroids, and given a 7 day course of oral steroids. Blood tests taken in hospital show a high Eosinophil count of 4.3% and the presence of a high titre of aspergillus antibodies, which may have been due to allergy to mould at home making her asthma worse. She is advised strongly to stop smoking and given contact numbers for the local quit smoking services.

Prior to discharge, the speciality registrar provided education on inhaler technique and PEF record keeping, with a written PEF and asthma plan to help the patient adjust her therapy within recommendations. The patient’s asthma clinic follow up has been arranged with the patient’s general practitioner the following day and with a hospital respiratory physician 5 weeks post admission to discuss her asthma management
CR2 - PBL6: Yvonne Seear
Teaching Material for this Session

Mrs Seear is a 67 year old woman with a substantial history of congestive cardiac failure who develops a cough, fever, back pain and malaise following a cold. She is visited at home by her GP who finds her temperature to be 40°C, pulse 130/minute, respiratory rate of 33/minute, blood pressure 95/65, Sp02 94%, with some crackles on auscultation at the right base. Physical examination revealed some sharp right-sided chest pain after a particularly long bout of coughing. She is given amoxicillin 1g prior to being admitted into hospital. At hospital, her vital signs are monitored regularly and an immediate chest X-ray reveals a lower right lobar-type pneumonia without effusion. Further tests reveal urea levels of 6.3 mmol/L. Oral therapy with amoxicillin and a macrolide is initiated within 4 hours of hospital admission. Blood cultures are assessed on admission. She is also treated with low molecular weight heparin.

On day 2 of hospital admission, Mrs Seear’s temperature, heart rate, respiratory rate and blood pressure are 38°C, 95 beats/min, 21 breaths/min and 101/69 mm Hg, respectively. After 4 days as an inpatient in hospital, she makes a successful clinical recovery. Prior to discharge, Mrs Seear is prescribed antibiotic therapy for a total of 10 days. A chest X-ray and follow-up appointment is arranged about 6 weeks after discharge. She is seen by her GP for a vaccination.
CR2 - PBL7: Edith Williams
Teaching Material for this Session

Edith Williams, a 60 year old woman who had a myocardial infarction and subsequent coronary bypass operation 5 years previously goes to her GP complaining of tiredness, shortness of breath (especially at night) and swollen ankles which are worse in the evenings. Recently she has been waking up suddenly after a couple of hours of sleep, with a feeling of severe anxiety and breathlessness. She now sleeps with several pillows under her head as she finds it difficult to sleep with only one pillow.

On examination the GP notes that her blood pressure is 160/95. Her pulse is 122 and there is slight pulsus alternans. Auscultation reveals a systolic murmur in her chest and crackles in the base of both lungs. Her ankles are slightly swollen. There is evidence of hepatojugular reflux. The GP sends her to the local hospital for an echocardiogram and a chest x-ray.

The hospital tests confirm his provisional diagnosis of heart failure. He starts her on drug therapy which he hopes will both relieve her symptoms and slow the rate of progression of her disease. Her adherence to this treatment is however patchy because she sometimes forgets. Her condition gradually deteriorates and she dies 6 years later.
CR2 - PBL8: Faisal Shah
Teaching Material for this Session

Faisal (age 19) is on remand awaiting trial at Pentonville Prison. He was arrested for soliciting as a male prostitute and dealing in cocaine. When examined by the prison doctor he complained of a persistent cough which stops him sleeping. When he does get some sleep he gets “drenched in sweat”. The doctor weighs him and measures his height. He weighs 55 kg and is 1.72 m tall. A physical examination reveals swollen lymph glands in both axillae. The doctor arranges for a chest x-ray and a skin test. When he has inspected the x-ray, the doctor arranges for a sputum test. In the meantime he prescribes medication for Faisal which he will have to take under supervision of a nurse in the prison infirmary. Finally he reports the details of Faisal’s case to the CCDC.

CR2 - PBL9: Kadeer Ahmed

Teaching Material for this Session

Kadeer Ahmed, aged 8 months, was the first born of parents who came from the same region of Pakistan. He had been a full-term normal delivery. He was successfully breast fed and initially thrived normally. However, over the past 2-3 months his parents had noticed that he was feeding poorly and that he appeared pale and had a swollen abdomen. On examination, he was clinically anaemic and his conjunctivae were mildly jaundiced. He had very little subcutaneous fat and a protuberant abdomen. The latter was due to a palpably enlarged liver and spleen. He was admitted for investigation and diagnosis. The results of the initial tests were as follows:

1) Blood count:

Component	Kadeer	Normal for age
Hb	6.1g/dL	11.0 – 14.0
MCV	67fL	70 – 85
MCH	21pg	25 – 30
Reticulocytes	150 x 109/L	30 - 100
WBC	11.6 x 109/L	6.0 – 16.0
Plts	300 x 109/L	200 - 550

2) Blood film and bone marrow morphology:

The blood film confirmed the presence of hypochromic microcytic red cells and the presence of circulating nucleated red cells. The bone marrow aspirate from the right posterior iliac crest showed a marked increase in erythropoiesis. There was increased macrophage activity with evidence of erythroid debris and iron in the cytoplasm.

3) Biochemistry:

Renal function normal

Liver function was normal apart from the following:-

Serum bilirubin 30 micromol/L (Normal less than 17)

Serum lactic acid dehydrogenase (LDH) 1500 U/L (Normal 240 – 480)

Further investigations of Kadeer and his parents were carried out.

4) Parent blood count

Component	Mother	Father
Hb	10.5g/dL (11.5-15.5)	11.0g/dL (13.5-17.5)
MCV	67fL (80-96)	68fL (80-96)
Reticulocytes	Normal	Normal
Serum ferritin	Normal	Normal

5) Hb A, Hb A2 and Hb F levels were measured.

Component	Mother	Father	Kadeer
Hb A	94%	95%	5%
Hb A2 (Normal <3.5)	5%	4%	5%
Hb F (Normal <1.0)	1%	1%	90%

Blood samples were sent to the National Haemoglobinopathy Service for DNA studies. When the results came back the Consultant Paediatric Haematologist explained to Kadeer’s parents a definitive diagnosis.

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Comment

Year 2 CR2: Cardiorespiratory 2

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