Students work book

MODULE

CARDIOVASCULAR

Academic year 2011-2012

CARDIOVASCULAR SYSTEM
MEDICAL FACULTY
HASANUDDIN UNIVERSITY
MAKASSAR
2011

Cardiovascular system :

INTRODUCTION
The best medical care for patients with cardiovascular disease primarily depends upon the best
diagnostic foundation provided by careful and in-depth history taking, and physical examination.
Many physicians are familiar with the so called five fingers approach to cardiovascular
diagnosis, popularized by Harvey. This consists of:
1.
2.
3.
4.
5.

History
Physical examination
Electrocardiogram
Chest X-ray
Various other laboratory tests

Although some cardiovascular disorders can be diagnosed with a single modality, a full
understanding of the patients problem usually requires the use information from several sources.
The history and physical examination may overlap each other in certain areas, but important
diagnostic information is often obtained while taking the history alone. When any abnormal
physical finding is demonstrated, of course, additional history pertinent to the finding will be
taken in order to confirm the clinical diagnosis. Special diagnostic procedures, such as cardiac
catheterization, echocardiography, nuclear scanning, treadmill test, ambulatory (Holter monitor)
electrocardiography, etc, are often necessary for accurate diagnosis and proper treatment.
This Dyspnoea module consists of three units. Each unit come with scenarios, studying
strategies, tasks, tutor guidance, some alternative questions and answers and some references.
The scenarios function as learning stimulus during the first session of group discussion,
with or without tutors. Students are expected to generate a number of questions with alternative
answers and its references. Unsolved problems are assigned as home works to be discussed on
the second session in another day.
Before using this book, students and tutors should have read the learning strategies, the
seven-jump method, learning objectives (GIOs and SIOs), so that the discussion will not diverge
elsewhere, and minimal competence required in the section will be achieved in an efficient time.
During this period of tutorial, the role of tutor to converge the discussion is very important.
Expert lectures will also be given if they are needed by experts in the field, and direct
expert consultations may be carried out after an appointment.

Cardiovascular system :

LEARNING STRATEGIES
1.
2.
3.
4.
5.
6.
7.

Group discussion without tutor, free brainstorming between students.

Group discussion guided by tutor to point the alternative question to the specific problem.
Consultation to the experts to acquire more in depth comprehension.
Specific lectures in the classroom.
Individual active learning in the library and electronic media.
Practical works in the skills laboratory.
Laboratory practices.

THE SEVEN-JUMP METHOD

1.
2.
3.
4.

Clarify terms and concepts in the problem unknown to you.

Define the problem : list the phenomena to be explained.
Explain the problem : try to produce as many different explanations for the phenomena.
Arrange the explanations proposed: try to produce a coherent description of the process
that, according to what you think of. Use prior knowledge and common sense.
5. Formulate learning goals/ learning objectives.
6. Attempt to fill the gaps in your knowledge through invidual study.
7. Share your findings with your group and try to integrate the knowledge acquired into a
comprehensive explanation for the phenomena.

STUDENT TASK
1. After reading the scenario carefully, students discuss about it in a discussion group of 12-15
persons. This discussion is conducted by a chairman and a writer from the students group.
The chairman and the writer should be changed each discussion time. Group discussion can
be conducted by a tutor or autonomously.
2. Apply individual study activity in the library using work books, magazines, slides, tapes or
videos, internet etc., to search for addition information.
3. Apply discussion group without tutor, do discussion between group to analysis or to
synthesis information in solving problem.
4. Apply consultation with source speaker that is expert in the problem to gain more
comprehension about the problem (ask expert).
5. Pursue specific lecture (expert lecture) in the class for problems that are not well understood
or havent found the answers.
6. Apply practicum in laboratories.

Cardiovascular system :

Addition Explanation:

If there is still information that is needed to reach the end conclusion from group report,
then process 6 can be repeated, and then do step 7 again.
Both steps above can be done repeatedly in the tutorial or outside the tutorial and in every
end of the discussion determine the goal of the next study. After the information is enough then
the report is due in the end of discussion, usually done in panel discussion where all the experts
sit together to give explanation about things that are not clear yet.

PROBLEM SOLVING PROCESS

In group discussion using discussion method, students are expected to be able to solve the
problem in the scenario, using the 7 steps of problem solving below:
1. Clarify the unclear terminology in the scenario above, and then determine the key
word/sentence of the scenario above.
2. Identify the basic problem of scenario by making several important questions.
3. Analysis and synthesis the gathered information by answering questions that had been made
above.
4. Classify the answers of the questions above.
5. Determine the study objective that want to be achieve by students group according to the
cases above.
Steps 1 to 5 are done in the self-discussion and the first discussion with tutor.
6. Students obtain more information about the cases above outside the group.
7. Students report the discussion result and the synthesis of information that is just discovered.
Step 7 is done in the discussion group with tutor.

ACTIVITY SCHEDULE
1. The first meeting in the big class with one direction of face to face by coordinator system
or MEU staff. This meeting explains about the module and the way of module
completion, and divides a discussion group. In this meeting the students is given Module
Work Book.
2. The second meeting is tutorial discussion; its conducted by students who are elected to
be the group chairman and writer, and also facilitate by two tutors. The objective is to
accomplish step 1 to 5 in problem solving process (brain storming) and divide tasks
between discussion group members.

Cardiovascular system :

3. The third meeting is tutorial discussion; its conducted by students who are elected to be
the group chairman and writer, and also facilitate by two tutors. The objective is to report
the self discussion result, do analysis and synthesis from the new information. The
process can be done again from step 5 of the problem solving problem.
4. Students study autonomously, alone or group. The objective is to search for new
information that is needed.
5. The fourth meeting is tutorial discussion. The objective is to report the last discussion
result and synthesis information that is just obtained. If new information is still needed,
continue it again like no. 2 and no. 3 above.
6. The last meeting is due in the big class in a panel discussion form to report each of the
group discussion result and ask about things that havent been answered to the expert
(expert meeting).

TIME TABLE
I

II

1st meeting
(overview
explanation)

Independent
meeting
(Brain
Stroming)

III

Tutorial I
Gathering
information
Analyse &
sintethyse

MEETINGS
IV

Independent
Practical
CSL

VI

VII

Lecture
Consultation

Tutorial II
(Report and
discussion)

Last meeting
(Report)

REFERENCES
A. Cardiovascular lectures from different field of studies.
B. Textbooks/Journals that are related to cardiovascular study.
1. Levick JR. (2003). An Introduction to Cardiovascular Physiology. 4th edit.Arnold
London.
2. Bickley LS (2003). Bates Guide to Physical Examination and History Taking. 8th edit.
Lippicott Williams & Wilkins, Philadelphia.
3. Braunwald E, Zipes DP, Libby P. (2001). Heart Disease A Textbook of
Cardiovascular Medicine. 6th edit. W.B. Saunders Coy, Philadelphia.
4. Fuster V, Alexander RW, ORourke RA. (2001). Hursts The Heart 10th edit.
International Edit. Mc Graw-Hill, New York
5. Chung EK. (1983). Quick Reference to Cardiovascular Diseases. 2nd
edit.J.B.Lippincot Coy, Philadelphia.
6. Crawford MH (2003). Current Diagnosis &Treatment in Cardiology. 2nd edit Lange Med
Books/McGraw-Hill, New York.
7. Coats A, Cleland JGF. (1997). Controversies in the Management of Heart Failure. 1st
edit. Churchill Livingstone, Edinburg.

Cardiovascular system
8. Branch WT Jr, Alexander RW, Schlant RC, Hurst JW.(2000). Cardiology in
Primary Care. Intern. Edit. McGraw-Hill, New York.
9. Braunwald E, GoldmanL. (2003). Primary Cardiology 2nd Edit. Saunders,
Philadelphia.
10. Hardjoeno H. dkk (2003) : Interpretasi Hasil Tes Laboratorium Diagnostik.LEPHAS.
Makassar.
11. Khan MG. (2003). Cardiac Drug Therapy. 6th edit.Saunders, Philadelphia.

LECTURERS
NAMA

NO

ALAMAT

NO. TELP
Rumah/flexi

HP

1 dr. Ali Aspar Mappahya,SpPD,SpJP

Jl. Sunu Komp Unhas A 7

453 453

0811416392

2 dr. Harfiah Djayalangkara

Jl Maccini Sawah

442 818

0811443235

3 dr. Arthur Koeswandi

Jl. Pongtiku

4 dr. Irawan Yusuf, PhD

Komp. Dosen Antang

5058294

5 dr. Agnes Kwenang

Jl. Sunu Komp Unhas DXl

434 639

6 dr. Baedah Madjid, SpMK

Jl. Sunu Komp Unhas AX 13

5702491

0811444326

7 dr. Gatot L Lawrence, SpPA

Jl. HOS cokroaminoto 29 B

312 365

0816255306

8 Prof.dr.Peter Kabo, Ph.D, SpFK

Jl. Muchtar Lutfi 21

320 348

0816275383

9 Prof.Dr.dr.Boy Pellupessy, SpA (K)

Jl. Pengayoman

081342759294
08152529560
081342347525

11 dr. Pendrik, SpPD

10 Prof.Dr.dr.Syakib Bakiri, SpPD

0816250620

12 dr. Ruland DN Pakasi, SpPK (K)

Komp. Kes. Banta-bantaeng

872 006

0816255713

13 dr. Arief Gella, SpRad

BTN Hamzy

585 235

04115078062

449 566
14

dr. Satriono, SpA(K)

15

dr. Nur Alim, SpB dr.

16

Tahir Abdullah

Jl. Sunu Komp Unhas AX 13

08124124652

Cardiovascular system

MODULE 1 DYSPNOEA

LEARNING OBJECTIVES
General Instructional Objectives (GIOs) :
After studying this module, the students will comprehend the basic concepts of dyspnoea-related
diseases and should be able to diagnose some cardiovascular diseases relating to this symptom.

SCENARIO 1
A 60 year old woman complain of feeling easily get tired and hard to breath when she is doing an
activity. She can not do chores longer without taking a rest because of hard breathing. Her legs
are swelling during the day, and lessen at night. Frequent breath and crepitating sound in
auscultations exam, are found from physical examinations. Artery pulse and blood pressure are
normal, but there is jugular vein obstruction when the patient in a standing position. Ictus cordis
is in anterior left of axillary line/intercostals V space. Her chest x-ray shows CTR 0,69 and the
lung vascular obstruction is indicated. The patient has been treated with digoxin and diuretic to
alleviate her symptoms.

SCENARIO 2
A 55 year old woman comes to a hospital with hardly breathe followed by a feeling of fast heart
beat when doing physical activities. In age 12, she was suffered from rheuma fever and there is a
murmur sound from her auscultation since. She has got atrium fibrillation since two years ago but
it is in control with digoxin 4 x o,25 mg. Vital sign : heart beat 80/min, blood pressure 130/80
mmHg, respiration 16/min. Weak wet ronchi is heard on both lungs. First heart sound (S1) is loud
and there is a single second heart sound (S2) with an opening snap (OS).

SCENARIO 3
A 67 year old man is treated in an emergency room with severe dyspnoea. He has been in a
hypertension treatment irregularly for a while, and has suffered myocardial infarct before. A
week prior to hospitalized, the patient complained substernal chest pain for more than 30
minutes, and has got worsen dyspnoea since. He could only sleep with three pillows to support
him on bed and always awake in the middle of the night because of dyspnoea. Physical
examination: no fever, blood pressure 160/100mmHg, heart beat 110/min, respiration 22/min and
80% O2 saturation. He is pale and sweating. Wet ronchi is found at the medio-basal of both lungs,
S3 and S4 are heard and no murmur. ECG shows pathological Q wave at V1-V4 .

Cardiovascular system

MODULE 2 CHEST PAIN

LEARNING OBJECTIVES
General Instructional Objectives (GIOs):
After studying this module, the students will comprehend the basic concepts of chest pain and
should be able to diagnose some cardiovascular diseases relating to this symptom.

SCENARIO 1
A 55 year-old man presents to the clinic with complaints of chest pain. He states that for the last
6 months he has noted intermittent substrenal chest pain radiating to the left arm. The pain
occurs primarily when exercising vigorously and is relieved with rest. He denies associated
shortness of breath, nausea, vomiting, or diaphoresis. He has a past medical history significant
for hypertension and dyslipidemia. His family history is notable for a father who died of
myocardial infarction at age 56. He has a 50 pack-year smoking history. His physical
examination is within normal limits with the exception of his blood pressure, which is 145/95
mmHg, with a heart rate of 75 bpm.

SCENARIO 2
A 35-year-old man presents to the emergency department with complaints of chest pain. The pain
is described as retrosternal, and sharp in nature. It radiates to the back, is worse with taking a
deep breath, and is improved by leaning forward. On review of systems, he has noted a flulike
illness over the last several days, including fever, rhinorrhea, and cough. He has no past
medical history and is taking no medications. He denies tobacco, alcohol, or drug use. On
physical examination, he appears in moderate distress due to pain, with a blood pressure of
125/85 mmHg, heart rate 105 bpm, respiratory rate 18/min, and oxygen saturation of 98% on
room air. He is currently afebrile. His head and neck examination is notable for clear mucus in
the nasal passages and a mildly erythematous oropharynx. The neck is supple, with anterior
cervical lymphadenopathy. The chest is clear to auscultation. Jugular veins are not distended.
Cardiac examination is tachycardic with a three-component high-pitch squeaking sound.
Abdominal and extremity examinations are normal.

Cardiovascular system :

SCENARIO 3
A collapse 60-year-old bus driver was brought into casualty complaining of severe, sustained
crushing pain in a band across the chest, spreading into the arms. Previously he had been well,
though he smoked 10 cigarettes a day. On examination he was pale, with cold, sweaty skin. His
pulse was weak, with occasional extrasystoles (ventricular ectopic beats). His arterial blood
pressure was 90/75 mmHg. Heart sound were normal. An ECG revealed large Q waves and ST
segment elevation. He was admitted with a provisional diagnosis of myocardial infarction due to
coronary artery thrombosis. Plasma analysis showed raised cardiac enzymes (lactic
dehydrogenase, creatine phosphokinase, aspartate aminotransferase). He was given O2 and
morphine. A streptokinase infusion was set up to lyse the coronary thrombus, and he was also
started on a regular, low dose aspirin.

Cardiovascular system

EEl

MODULE 3 CONGENITAL HEART DISEASES

LEARNING OBJECTIVES
General Instructional Objectives (GIOs):
After studying this module, the students will comprehend the basic concepts of Congenital Heart
Diseases and should be able to diagnose some cardiovascular diseases relating to this symptom.

SCENARIO 1
A ten year old girl comes with her lips and fingers blue. This has happened since she was a baby.
This worsens when she cries or plays. She often have to sit on her knees when she is tired
playing. Physical examination shows small and skinny appearance. Cyanosis appears on her lips,
end of her tongue, her fingers and toes. Pulse and blood pressure are normal. Thorax examination
reveals right ventricle activity increases, followed by thrill at LSB 3. Heart sound 1 and 2 are
pure, intensity increases. Systolic ejection murmur (degree 3/6 p.m LSB 4), is found. Femoral
artery palpation is normal. Shes got drum stick fingers.

SCENARIO 2
A four year boy is brought to a hospital because he always looks hard to breath and easy to get
tired when he plays. He has suffered these since he was a baby. He never looks cyanotic. He
always suffers from recurrent cough-sniffle and sweating. Physical exam shows small and skinny
appearance. Cyanosis (negative). Pulse and blood pressure are normal. Chest X-Ray: voussure
cardiac (+). Right and left ventricle activity increase. Thrill is palpable at LSB 4. Louder heart
sound 1 and 2. Pansistolic murmur is heard grade 4/6, p.m. at LSB 4 spread to RSB, axillaries
and suprasternal. Femoral artery is palpable normal. No drumstick fingers.

SCENARIO 3
A ten year old girl comes with pain and swelling left knee, fever, palpitation. This has happened
since three days ago. Physical exam shows cyanosis (-), pulse 140/minute regular. Blood pressure
120/60 mmHg. Temperature 38 Celsius degree, DVS normal. Thorax exam: left ventricle activity
increases. Thrill is palpable at apex. Heart lining is widen. Pure heart sound 1 and 2, normal
intensity. Systolic murmur is heard, diastole grade 2 3/6, p.m. at apex. Femoral artery is
touched bounding. No drumstick fingers. Inflammatory sign at her left knee (+).