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Rationale

Chronic congestive heart failure ranks among the most common of cardiac problems. Identification and correction of treatable underlying causes, elimination of precipitating factors and judicious use of multidrug regiment for individuals with CHF are important issues for third year medical students.

Prerequisite

Prior knowledge, skills, and attitudes acquired during the pre-clinical (basic science) years should include:

  1. structure and function of heart and lungs
  2. epidemiology of heart disease
  3. pathogenesis and pathophysiology of cardiovascular disease
  4. pharmacology of cardiovascular drugs
  5. ability to communicate with patients of diverse backgrounds
  6. ability to take a medical history and perform a physical exam
  7. understanding the impact of illness on individuals and their families
  8. ability to perform a cardiovascular risk assessment
  9. ability to understand the importance of prevention of cardiovascular disease and be able to communicate appropriately to all patient groups, including the elderly patient

Specific Learning Objectives

  1. Knowledge: Students should be able to define and describe:
    1. types of processes (i.e. ischemic, valvular, cardiomyopathy, infiltrative, inflammatory) and most common disease entities that cause CHF
    2. types of processes that cause systolic vs. diastolic dysfunction
    3. signs and symptoms of left-sided vs. right sided heart failure
    4. compensatory mechanisms in heart failure
    5. factors leading to exacerbation of CHF including hypoxemia, anemia, fever, hypertension, tachyarrhythmia, and hyperthyroidism
  2. Skills: Students should demonstrate specific skills including:
    1. history-taking skills: Students should be able to obtain, document, and present an age-appropriate medical history, that differentiates among etiologies of disease, including the presence or absence of the following:
      1. dyspnea
      2. orthpnea
      3. paroxysmal nocturnal dyspnea (PND)
      4. peripheral edema
      5. fatigue and decreased exercise tolerance
    2. physical exam skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease including:
      1. measurement of arterial blood pressure
      2. assessment of major arterial pulses for abnormalities, including bruits
      3. assessment of eye ground changes, specifically of the conjunctiva and retina
      4. assessment of the extremities, to ascertain skin condition, including color and temperature; presence of edema; cyanosis and presence of clubbing
      5. assessment of the lungs for rales, rhonchi and decreased breath sounds
      6. inspection and palpatation of the anterior chest to identify right- and left-sided heaves and thrills
      7. assessment of the heart, including rhythm, intensity of heart sounds, splitting of S2, and presence of murmurs, rubs, gallops, or extra sounds (e.g., clicks)
      8. assess abdomen, to determine the presence of hepatomegaly, splenomegaly, hepatojugular reflux, ascites, abnormal masses, pulsations, and bruits
    3. differential diagnosis: students should be able to generate a prioritized differential diagnosis recognizing specific history and physical exam findings that confirm or refute CHF distinguishing between:
      1. pericardial
      2. endocardial
      3. valvular (congenital, acquired)
      4. endocarditis
      5. myocardial
      6. hypertrophic
      7. restrictive
      8. congestive
    4. laboratory interpretation: Students should be able to recommend when to order diagnostic and laboratory tests and be able to intrepet them, both prior to and after initiating treatment based on the differential diagnosis, including consideration of test cost and performance characteristics as well as patient preferences
      1. laboratory and diagnostic tests, when appropriate, should include:
        • chest x-ray
        • ECG baseline and during exercise testing
        • exercise testing (for functional capacity)
        • echocardiography (2D, TEE)
        • radionuclide gated blood pool scintigraphy (LVEF)
      2. laboratory and diagnostic tests that one should be able to define the indications for and interpret the results of include:
        • ECG baseline and during exercise testing
        • exercise testing (for functional capacity)
        • echocardiography (2D, TEE)
        • radionuclide gated blood pool scintigraphy (LVEF)
    5. communication skills: Students should be able to:
      1. communicate the diagnosis, prognosis and treatment plan of the disease to patients and their families
      2. educate patients about cardiovascular risk factors including:
    6. basic procedural skills: Students should be able to perform:
      1. EKG
      2. arterial blood gases
    7. management skills: Students should be able to develop an appropriate evaluation and treatment plan for patients including:
      1. non-pharmacological management:
        • sodium restriction
        • physical activity
        • coronary revascularization
        • heart transplantation
      2. pharmacologic management:
        • diuretics
        • vasodilators
        • positive inotropic agents
        • ACE inhibitors/ calcium channel blockers
        • antiarrhythmic agents
        • anticoagulants/antithrombotic agents
        • how critical pathways or practice guidelines in ambulatory patients or patients hospitalized with CHF can be used to guide diagnostic test ordering
        • accessing and utilizing appropriate information systems and resources to help delineate issues related to CHF
  3. Attitudes and Professional Behaviors: Students should be able to:
    1. recognize the importance of lifestyle limitations caused by CHF (and counsel patients appropriately)