Please, refer to the ECG Skills Checklist

a clinician’s physical examination. In our opinion, the appreciation of cardiac anatomy and hemodynamics by bedside echocardiography makes a physician’s clinical evaluation, including physical examination, more relevant to the care of patients. For all physicians who care for patients with a cardiovascular problem, it is essential to know how echocardiographic images are obtained, what type of information echocardiography can provide, and how it should be used for management. Reference: 1. Mann, DL et all. Braunwald’s Heart Disease, 10 th ed. Philadelphia, Elsevier Saunders, 2015. p. 118-132 SELF DIRECTING LEARNING Basic knowledge that must be known: 1. ECG procedure. 2. ECG Interpretation . TRAINING TASK ECG Procedure : Preparation Group should choose one of their members to become a patient for the ECG examination. Ask the patient to lie down on the table. In turn, each the student should perform the ECG Examination; student should start from patient preparation, setup the machine, recording step, and obtaining the result. Instruction: 1. Prepare the patient for ECG examination. 2. Set the electrocardiography appropriately. 3. Place the leads in appropriate position. 4. Start the examination. 5. Obtain the result properly. 6. Explain and give information to the patient.

7. Please, refer to the ECG Skills Checklist

Independent Learning ECG Interpretation Each group will be provided with 10 pieces of electrocardiogram. Student should be familiar with the analyzing step for the ECGram. It is likely that student should start from checking the patient ID, analyze the rhythm, and identify whether there are any abnormality patterns. Student should also be familiar with the writing technique for the ECGram’s interpretation. Instruction 1. Analyze the ECGram given in group. You should refer to the handout given Analyzing the ECG for the interpretation 2. Write down the interpretation made for each ECGram. Discuss the result at wrap up session. Udayana University Faculty of Medicine, DME 40 Day 14 MODULE 14 dr. Lisnawati, Sp.Rad dr. Made Muliarta, M.Kes AIMS: 1. Able to evaluate and result chest x-rays 2. Able to workload measurement LEARNING OUTCOME: 1. Able to evaluate chest x-rays, including evaluation on heart, lung, diaphragm, skeleton and soft tissues 2. Able to result chest x-rays 3. Able to workload measurement CURRICULUM CONTENS: 1. Able to evaluate chest x-rays, including evaluation on heart, lung, diaphragm, skeleton and soft tissues 2. Able to result chest x-rays 3. Physiologic parameters during activity ABSTRACT I: Chest imaging is important evaluation that supports the diagnosis procedure. Student should be able to evaluate chest x-rays, including evaluation on heart, lung, diaphragm, skeleton and soft tissues. After evaluation, student should be able to write down the result in a given format. Some emergency case, need rapid chest x-rays evaluation. By this training we hope that the student will be able to do such important skill. There are steps in evaluating the chest x-rays, it is systematic steps. The student should be mastered. For cardiovascular system the chest imaging will be posterolateral, lateral, oblique projection. Student should evaluate the heart size; identify any enlargement, the condition of the lung – any edema, arterial and venous hypertension. The imaging investigation of the heart may be considered under the following: 1. Chest X-ray 2. Computed tomography CT-scan 3. Magnetic resonance imaging MRI 4. Echocardiography 5. Angiocardiography 6. Cardiac catheterization 7. Isotope scanning Chest X-ray remain the valuable cardiac investigation in clinical practice. Radiologic method used in the roentgen cardiac examination: 1. Posteroanterior projection, PAAP 2. Lateral projection 3. Right anterior oblique projection RAO 4. Left anterior oblique projection LAO Increase in cardiac size is the most consistent indication of cardiac disease ABSTRACT II: Physiologic parameters will be change during activity, such as heart rate, stroke volume, and cardiac output, blood pressure, peripheral resistance, and oxygen concentration. Some or those parameters could be measure with a very simple technique Udayana University Faculty of Medicine, DME 41 by calculating the arterial pulse, while others could only be measure using specific tools such as ergo meter, ECG, and treadmill. In practice, we could measure the cardiovascular functional capacity by using arterial pulse method, pulse meter, and ECG. Stress test or exercise test should be done for patient with heart disease in special place, in the laboratory. The purposes of stress test are to make quantification of heart disease suffered by the patient and to evaluate the functional capacity of the patient. The arterial pulse in rest condition will reflect the health status of the patient. The working arterial pulse will reflect the workload, and the recovery pulse rate will also reflect the fitness status of the patient. We will use the Karvonen Formula to calculate the heart rate limit on stress test. The ten pulse method is the method for calculating the arterial pulse during activity and recovery period. SELF DIRECTING LEARNING Basic knowledge that must be known: 1. Able to evaluate chest x-rays, including evaluation on heart, lung, diaphragm, skeleton and soft tissues. 2. Physiologic parameters during activity. TRAINING TASK I: Chest imaging: Cardiovascular System Preparation There would be 10 set of light cast with a single x-ray film. The group should discuss the x-ray film and write down the result in a piece of A 4 paper. You should notice the time limit for each film. It would be at least 5 – 10 minutes of discussion for each film. Group should move to another x-rays film after complete the discussion and writing down the result. Instruction 1. Group should read the case available before evaluate the x-ray photo. What is the main complaint of the patient? 2. The group should evaluate the x-rays photo systematically 3. Write down the group result on a piece of A4 paper. 4. Move to another x-rays and you should repeat the step 1 till 3 each group should read all photos available. TRAINING TASK II: Home Work: Determine Your Workload by Arterial Pulse Evaluation Question: will be given after the lecture Student should work the task individually. Write down the answer on a piece of A4 paper and make sure you put your name and NIM on it. Collect your work at Lab Faal on Monday, April 27 th , before 11 am Standard References : 1. Roentgen Signs in Diagnostic Imaging Isadore Meschan Udayana University Faculty of Medicine, DME 42 Day 15 MODULE 15 Prof. Dr. dr. Wiryana, Sp.An KIC AIMS: 1. Able to skill routine clinical procedure: Intravenous Line IV line 2. Able to LEARNING OUTCOME: 1. Able to two skills should be trained : IV cannulation and venipuncture.. CURRICULUM CONTENS: 1. Technique of venipucture 2. Aseptic procedure . ABSTRACT : Doctor should be able to draw blood in field setting as a part of disease investigation and therapy. Appropriate equipment and supplies should including the following gloves, aseptic kit, bandage, tourniquet, vacutainer tubes or spuit and the container. The complete technique of venipucture is contained in the Venipucture Evaluation Checklist. It will cover the skills in preparation of the doctor and the patient, aseptic procedure, the preparation of the kit, communicate the procedure to the patient, the patient preparation, the insertion technique of the needle, the blood collection, evaluation for any bleeding, and cleaning the work area after the procedure. The checklist will vary from one to another, you should use the checklist as aide- memoir or reminder of the element skills to be done. Basically there would be four main steps in doing the venipuncture and IV line cannulation. It would be explain the procedure, prepare the equipment and positioning the patient, select appropriate site, use standard precaution, and reach the goal obtain adequate specimen and a good technique for cannulation. SELF DIRECTING LEARNING Basic knowledge that must be known: 1. The complete technique of venipucture 2. Aseptic procedure 3. The preparation of the kit 4. Communicate the procedure to the patient 5. The patient preparation 6. The insertion technique of the needle, the blood collection 7. Evaluation for any bleeding 8. Cleaning the work area after the procedure TRAINING TASK Venipuncture and IV Line Procedure Preparation Udayana University Faculty of Medicine, DME 43 We will provide the student with Multipurpose Injection Arm and IV line manequin needed for IV line procedure training. It would be at least one mannequin for each two groups. Groups should prepare one infusion set, ringer lactate infusion fluid, antiseptic set, and tape. Each student should bring their own IV needle G-21, syringe 3 cc, and bring glove for antiseptic procedure. Instruction 1. There would be two skills should be trained in this session, IV cannulation and venipuncture. 2. You have to prepare the set for the procedures, prepare the manequin, needle, the infussion set, and the infussion fluid. 3. Demonstrate how will you explain the procedure to the patient, the technique and the complication might be happened. 4. Demonstrate the technique for IV cannulation and venipuncture. Please notice the position of your finger, the angle, and how to evaluate whether the needle inserted properly. 5. Refer to the checklists Venipucture and IV Cannulation for any details 6. Ask any comment and score for ypur perfomance from your groups based on the checlist MODULE 16 dr. Eka Guna Wijaya, Sp.A AIMS: 1. Describe Non-cyanotic and Cyanotic Congenital Heart Diseases 2. Describe to diagnose and manage Acute Rheumatic Fever LEARNING OUTCOME: 1. Can describe to diagnose and manage Non-cyanotic and Cyanotic Congenital Heart Diseases 2. Can describe to diagnose and manage Cyanotic Congenital Heart Diseases 3. Can describe to diagnose and manage Acute Rheumatic Fever CURRICULUM CONTENS: 1. Fetal-transitional circulations 2. To diagnose and manage Non-cyanotic Congenital Heart Diseases and its complications 3. To diagnose and manage Cyanotic Congenital Heart Diseases and its complications 4. Interpret diagnostic tools of Congenital Heart Diseases 5. The health education and prognosis of Congenital Heart Diseases 6. Interpret diagnostic tool of Acute Rheumatic Fever 7. Management of Acute Rheumatic Fever and its complications 8. Prevention and rehabilitation of Acute Rheumatic Fever 9. Health education and prognosis of Acute Rheumatic Fever Udayana University Faculty of Medicine, DME 44 Day 16 ABSTRACT I: Congenital Heart Disease CHD is congenital malformation of the heart including great vessel that was occur since the baby was delivered. A lot of kind of CHD has been recognized but ventricular septal defect, atrial septal defect, patent ductus arteriosus were the most common finding. Tetralogy of Fallot is the commonest one of cyanotic CHD. Obstructive lesions pulmonary and aortic stenosis, coarctatio aorta, transposition of great artery, truncus arteriosus, ebstein anomaly, etc were relatively rare cases. CHD is really a dynamic disease. In mild and simple lesion such as VSD and ASD were usually asymptomatic and half of those may undergoing spontaneous closure after two years old. Contrassly in severe cases, sign of heart failure, deep cyanosis, acidosis and other sign express of critical condition may exist in few hours after birth. Severe pulmonary hypertension is serious longterm complication of large left-to- right shunt. Eisenmenger syndrome may slowly develop when pulmonary artery pressure higher than systemic pressure. The patient appeared cyanotic who previously non cyanosis. Left-to-right shunt hemodynamically characterized by increase of pulmonary blood flow but inversely decrease of systemic blood flow. Under these circumstances may lead to congestive heart failure due to overcompensated of symphatic and humoral stimulation. ToF may characterize by four anatomical abnormalities: VSD, overriding of aorta, right ventricular hypertrophy, and pulmonary stenosis. Right-to-left shunting was seen in ventricular level. Severity of cyanosis in ToF depends directly on severity of pulmonary stenosis. Growth failure is the commonest finding of significant CHD. Screening should be done in patient with failure of growth and development and certain syndromes to evaluate more carefully in other to be sure is the patient having or not having of CHD. Diagnosis investigation of CHD was the following: history taking antenatal, natal, and post natal, physical examination, chest radiograph, and ECG. Echocardiography is needed to evaluate more detail of anatomical defect and cardiac function. Comprehenship management should be performed in nursing the patient. Dental hygiene, nutritional support, psychological aspect was a part of integrated management beyond of the medical and surgical intervention. ABSTRACT II: Valvular Heart Disease VHD is largely variated disease due to anomaly or damaged of one or more cardiac valves. Anomaly most likely congenital in origin include: Tricuspid Atresia, Tricuspid Steno- insuficiency Ebstein anomaly mitral stenosis, mitral insufficiency, pulmonary or aortic stenosisatresia. The most common of VHD is Rheumatic Heart Disease and Mitral Valve Prolaps. Diagnosis investigation like other disease: History taking, physical examination, chest X-rays, ECG, and other specific laboratory examination. Echocardiography is routine procedure to evaluate more detail anatomical abnormality, severity and cardiac function. Catheterization is needed when valvuloplasty was indicated. The origin and characteristic of the first and the second heart sound should be deeply understand before indentified many kind of pathological heart murmur. Location, timing, quality, intensity, and transmission of heart murmur is the basic auscultative modality to investigate more advance of specific valvular heart disease. Management of VHD medically include: digitalis, diuretics, vasodilator, anti thrombotic agent, endocarditis prophylaxis, dental hygiene and nutritional support. Rheumatic fever Rheumatic Heart Disease was agreed worldwide as an autoimmune disease. Tissue hospes has mimic antigenic structure with certain strain of beta hemolytic streptococcus group a who was infected in the pharing. There is basic pathogenesis Udayana University Faculty of Medicine, DME 45 concept in development tissue injury damage of succeptible host. When autoantibody was generated in significant number, cross reaction where streptococci causing agent were killed naturally by humoral and cellular antibody but on the other hand tissue damage of the hospes was also happen because it was recognized as antigen. Carditis and arthritis were the most frequent of major symptom of RFRHD. Jones criteria was established as definite diagnosis of rheumatic fever. Evolution was made from the beginning in 1944 and then revised in 1956, modified in 1965, update in 1992, finally recommendation of WHO in 2002. Bed rest, eradication of causing agent, inflammatory drug and secondary prophylaxis were the basic management of Rheumatic Fever Rheumatic Heart Disease Standard References: 1. Park, MK. Pediatric Cardiology for Practioners. 4 th Ed. Philadelphia, Mosby. 2002. p 129-144, 185-189, 304-310, 311-318 SELF DIRECTING LEARNING Basic knowledge that must be known: 1. Fetal-transitional circulations 2. Criteria diagnose and manage of the Non-cyanotic Congenital Heart Diseases and its complications 3. Criteria diagnose and manage of the Cyanotic Congenital Heart Diseases and its complications 4. The health education and prognosis of Congenital Heart Diseases 5. Interpret diagnostic tool of Acute Rheumatic Fever 6. Management of Acute Rheumatic Fever and its complications 7. Prevention and rehabilitation of Acute Rheumatic Fever 8. Health education and prognosis of Acute Rheumatic Fever. SCENARIO; CASE 1: Putu, 2 years old girl was came to pediatric cardiology clinic with her parent with the main complain of persistent cough and slight dyspneu. Physical examination : HR : 128 xmin, RR : 44 xmin, BW : 9 kg. Positive precordial bulging, cardiac impulse was displaced to caudolateral associated with lifting. Heart murmur was heard systolic and diastolic phase at upper left parasternal border. LEARNING TASK : 1. How to know that patient having continuous murmur. 2. What is the probable complete diagnosis clinically. 3. Is the patient should be given indometasin. 4. What is the best diagnostic tool in this patient. 5. What kind of treatment have been recommended. CASE 2: Made, 9 months old baby was referred by GP to pediatric clinic of cardiology due to cyanosis. Physical examination looked at the baby having cyanotic at the mouth until the tongue. Cyanotic was also seen at the fingers associated with clubbing. When auscultation just to be done, the baby suddenly hard crying, uncontrolled for long time and then hyperapneu and lethargy. LEARNING TASK: Udayana University Faculty of Medicine, DME 46 1. What is may be happen to the baby. 2. What must you be done immediately to overcame this condition. On auscultation, ejection systolic murmur was heard at the upper left parasternal border line with almost there is no heard of P2. 3. What is the most probable disease may be occur to the baby 4. What does you expected from chest X-ray examination. 5. When phlebotomy should be perform base on routine blood examination 6. Mention a lot of complication may be develop and what is the most hazard 7. When iron preparation should be given in this patient. CASE 3: Komang, 10 years old boy come with his parent to pediatric clinic of cardiology with the main complain of dyspneu on exertion. Coughing and palpitation were also present. Physical examination revealed: Malnourish boy with slight anemic. Pulse rate : 108 x min, RR : 24 xmin, body temperature 38 degree C. Hyperdinamic of precordium with displacement of apical impulse caudolaterally with lifting positive. Holosystolic murmur was heard at cardiac apex referred to axilla. Diastolic murmur was also heard at upper right parasternal border. LEARNING TASK 1. Base on those data, what is the most probable diagnosis. 2. What is other history and laboratory examination may be needed to support the diagnosis. 3. Which of cardiac valve were involve in this patient. 4. How about chest X ray and blood pressure examination. 5. How to manage in short and long time period. SELF ASSESSMENT 1. Please describe haemodynamic change in PDA. 2. Patten of blood pressure and pulse in PDA. 3. How the chest X-ray in patient with PDA. 4. Is in large PDA you can heard diastolic flow murmur at the apex cordis? Can you explain about that? 5. Please mention complication of PDA. 6. Please mention a few risk factor in development of cyanotic spell. 7. Can you explain the phatomecanism of cyanotic spell? 8. Please mention differential diagnosis of cyanotic CHD base on increase and decrease of pulmonary blood flow. 9. Please explain what do you know about pheriperal and central cyanosis. 10. Explain phatomecanism oh tissue injury in acute rheumatic fever 11. Mention etiology, antigenic structure and it’s cellular product. 12. Please mention mayor and minor manifestation of rheumatic fever. 13. Please mention detail pathology of rheumatic fever. Udayana University Faculty of Medicine, DME 47 Day 17 MODULE 17 Dr. dr. K. Rina, Sp PD, Sp JP AIMS: Describe to diagnose and manage Ischaemic Heart Disease IHD and Acute Coronary Syndromes ACS LEARNING OUTCOME: 1. Can describe to diagnose and manage Ischaemic Heart Disease IHD

2. Can describe to diagnose and manage Acute Coronary Syndromes ACS