Name: BANI SAEID HASSAN

Gp:7608M2a
MINISTRY OF HEALTH OF UKRAINE
National Bohomolets Medical University

WORKBOOK

For The Self-study of students 5 th year

Training course "Internal Medicine" Module 2
Directly "Medicine"
Specialty "Medicine"
Department of Internal Medicine №2

Topic 21: "Congenital heart disease"

Considered and approved by t

he cyclic methodical commission of therapeutic disciplines
on _____________201__ g.,
Protocol № _____
 INTRODUCTION

One of effective means organization of independent work of students on the topics of

discipline that designated for independent study is the work of student workbooks. Work on
workbooks should begin with a review key questions on the topic. The next step is get acquainted
with a list of sources where students can find answers to questions. For a more deep study of the
problem the student can apply for professional websites.
After reviewing the theory, the student is necessary to assess the degree of learning. In this
regard it solves proposed tasks, test questions on the topic. Particular attention while preparing for
classes the student must pay on the necessary minimum of practical skills that he must learn. The
relevant sections of textbooks, manuals, he has to learn the information that he needs for mastering
the practical skills.
Organization of independent work by means of workbook is as follows: the teacher presents
workbook to the student either on electronic media (on the cathedral website) or in printed form,
then students perform tasks durring extracurricular time, later teacher checks it and evaluates it
durring the initial phase of practical classes.
Criteria for estimation tasks workbook
Each task requires an individual approach in assessing the quality of its performance with its
criteria. The 5-point evaluation of each type of tasks should follow the general didactic criteria,
namely:
Mark "5" refers if the student:
1. Completed work without error and drawbacks.
2. Completed wor with no more than one mistake
Mark of '4' refers if the student completed the work completely, but admitted it:
1. No more than one non rough errors and a single drawback.
2. No more than two drawbacks.
Mark "3" refers if the student correctly completed at least half the work or did:
1. No more than two gross errors or no more than one non rough mistakes and one drawback;
2. No more than two or three non rough errors or mistakes, or a single rough error and three
drawbacks;
3. In the absence of errors, but with four to five drawbacks.
Mark "2" refers if the student:
1. made a number of errors (drawbacks) that exceeds the rate at which may be set mark "3".
2. If correctly executed less than a half of work.
3. Did not proceeded to do the work.
4. Properly performed no more than 10% of all work
Topic 21: "Congenital heart disease"
The purpose (learning objectives): to teach students to identify the main clinical signs of congenital
heart disease with increased pulmonary blood flow (ventricular septal defect, atrial septal defect,
patent ductus arteriosus), Eisenmenger's syndrome and coarctation of the aorta, to designate
diagnostic and therapeutic tactics and to make timely referral to surgical treatment.

The student should know:

1. The basic classification of congenital heart disease in adults with pulmonary blood flow and
presence/absence of cyanosis, the risk factors of congenital heart diseases .
2. Mechanisms of hemodynamic changes and their compensation in the atrial septal defect,
ventricular septal defect, patent ductus arteriosus, definition of pulmonary hypertension, its type and
extent, and methods of estimating pulmonary artery pressure in the clinic.
3. Diagnostic value of ECG in these congenital heart defects and ECG changes in case of
hypertrophy of the ventricles and atria.
4. Diagnostic criteria for radiography of the chest in these congenital heart defects and
configuration changes of the heart.
5. Diagnostic value of Echocardiography, in particular dopplerechocardiography, in congenital heart
defects.
6. Diagnostic possibilities of invasive methods (catheterization of heart cavities, angiocardiography
x-ray contrast).
7. Differential diagnosis of atrial septal defect, ventricular septal defect, patent ductus arteriosus
among themselves, as well as with acquired defects, which are accompanied by systolic murmur.
8. Complications of congenital heart disease.
9. The definition of Eisenmenger's syndrome, its causes, pathogenesis, changes of cardiac
hemodynamics, clinic, diagnostics, differential diagnosis with other causes significant shortness of
breath and cyanosis, medication.
10. Indications and contraindications for surgical intervention for these defects.

The student should be able to:

1. Based on the survey and physical examination, routine methods of data –ECG, x-ray examination
of the chest cavity to substantiate clinical suspicion of congenital heart disease, Eisenmenger's
syndrome.
2. Make a plan of examination to identify congenital heart defects in patients with dyspnea,
cyanosis and a heart murmur.
3. To evaluate ECG data for hypertrophy of the ventricles and atria, radiography of the chest and
Echocardiography (cardiac cavity, wall thickness, systolic pulmonary artery pressure) and to
determine their diagnostic value when an atrial septal defect, ventricular septal defect, patent ductus
arteriosus, in particular in the phase of Eisenmenger's syndrome, and coarctation of the aorta.
4. To formulate clinical diagnosis of these malformations.
5. To determine the indications for surgical treatment and principles of drug therapy of
Eisenmenger's syndrome.
The key terms of the topic
Term Definition

Term Definition Term Definition

Heart disease Is organic lesion of the heart valves, septa, major blood vessels and
myocardium, which leads to poor function of the heart, stagnation of
blood in the veins, tissues and organs. There are simple and combined
heart diseases.
Patent ductus Abnormal communication between the aorta and the pulmonary artery
arteriosus that remains steadily in the post-natal period.
Pulmonary Increase in the everage of pulmonary artery pressure over 25 mm Hg at
hypertension rest and over 30 mmHg during physical loading.
Pulmonary arterial Predominant increase in blood pressure in prekapilliary bed with a small
hypertension circle of blood circulation.
Pulmonary venous primary increase in arterial pressure in the post capillary bed of the
hypertension small circle of blood circulation.
Eisenmenger's High pulmonary hypertension with an abrupt increase pulmonary
syndrome vascular resistance in patients with congenital heart defects with the
presence of the pathological message between a large and small circle of
blood circulation, which leads to right-left, venous-arterial discharge of
blood and the appearance of cyanosis

Literature main:
1. The Merck Manual of diagnosis and therapy. Eighteenth Edition – Mark H. Beers, Robert S.
Porter, Thomas V. Jones et all. - Merck Research Laboratories, 2008 – P.2404-2421.
2. Cardiology. Crash Course. Third Edition – Ajay Jain, Matthew Ginks – Mosby Elsevier,
2008.- P. 177-187.

Literature additional

3. Guidelines on the management of valvular heart disease (version 2012) European Heart Journal
(2012) 33, 2451–2496 doi:10.1093/eurheartj/ehs109

4. The Society of Thoracic Surgeons. Adult cardiac surgery database, executive summary, 10 years STS
report. http://www.sts.org/sites/default/files/documents/
pdf/ndb2010/1stHarvestExecutiveSummary%5B1%5D.pdf

5. http://eurheartj.oxfordjournals.org/content/ehj/36/44/3075.full.pdf

The tasks for the independent study of topics (which should be presented in the ritten
form)
Option 1.
Task 1.
Factors that increase the risk of malformations, especially in the first trimester of pregnancy (fill in
the table):
1 Some viral infections (measles, influenza);
2 Diabetes.
3 Medications

4 Drinking alcohol during pregnancy

5 Smoking.

Task 2.
Fill in the table of clasification the major congenital heart diseases in accodens with
pulmonary blood flow:
Pulmonary blood flow
reduced retained
Stenosis of the pulmonary artery VSD
ASD
Tetralogy of Fallot

Task 3.
According to the presence of diffuse cyanosis list the "white" and "blue" cardiac defects:
1. 1. "white" defects With RV enlargement : ASD , PS .
● • With LV enlargement : AS, PDA, Coarctation of aorta. .__,
● • With biventricular enlargement : VSD .
● • With NO ventricular enlargement: : Any mild lesion ,
Dextrocardia

● 2. "blue" defects Fallot's tetralogy ( F4 ) Fallot's pentalogy ( FS ) : F4 + ASD -- ../

●
● • Fallot's triology ( F3 )
● • Eisenmenger's syndrome.

● • Tricuspid atresia.
● - ...._,/
● • Transposition of the great arteries.
Task 4.

Write the possible complications of congenital heart diseases with increased pulmonary blood flow:
1. Hemoptysis
2. pulmonary hypertension
3. right sided heart failure
4. Eisenmenger syndrome

5. arrythmia

Task 5.
Select the ECG – signs of hypertrophy of the atria:
p-mitrale–– Abnormal Q waves may be seen, though less commonly than in hypertrophic
cardiomyopathy. Abnormal Q waves are most often seen in leads V1 to V4 and may mimic the
appearance of a myocardial infarction.

p-pulmonale– – Right atrial enlargement produces a peaked P wave (P pulmonale) with amplitude:
>
2.5 mm in the inferior leads (II, III and AVF) > 1.5 mm in V1 and V2.

Task 6.
List arcs of the left contour of the heart: ●left paratracheal stripe
made up of left common carotid artery, left subclavian artery and the left
jugular vein ● aortic arch +/- aortic nipple (left superior intercostal vein)

● pulmonary trunk
● auricle of left atrium
● left ventricle
Test questions.
Select one correct answer:
1. Which of the following statements is correct for coarctation of the aorta?
A. Systolic murmur in the III-IV intercostal space to the left of the sternum.
B. There is an increase in BP in the upper and the decreased blood pressure in the lower
extremities.
C. Hypertrophy of both ventricles and dilatation of the left atrium.
D.In auscultation there is systolic-diastolic murmur in the second intercostal space on the left edge
of the sternum.
E.There is the tone of Traube over the femoral artery duaring auscultation.

2. In the case of atrial septal defect we may reveal:

A. Moderate systolic murmur and accent of the II tone in the II intercostal space to the left.
B. Revealed expansion of the boundaries of cardiac dullness to the right due to dilatation the right
atrium and the right ventricle.
C. ECG reveals complete or incomplete blockage of right atrioventricular bundle.
D. All of the above is not true.
E. All of the above is true.

3. Enlargement of the right ventricle of the heart is characteristic of:

A. Aortic stenosis.
B. Defect of interatrial septum.
C. Insufficiency of the aortic valve.
D. Insufficiency of the mitral valve.
E. Coarctation of the aorta.

4. Which of the following statements is correct for a defect of the interventricular septum?
A. There is a revealed rough systolic murmur at the apex which is radiated to the axillary region.
B. Specific systolo-diastolic murmur over the pulmonary artery.
C. Frequent complication is atrial fibrillation.
D. Frequent complication is Eisenmenger's syndrome.
E. Lung fields are not clearly observed.
5. What are ECG-signs of hypertrophy of the right ventricle:
A. Deep S in V1-V2 leads, tall R in V5-V6 leads.
B. Increase in the amplitude of the R wave in V1-V2 leads and S amplitude in V5-V6 leads.
C. Deep S in V1-V2 leads and negative T in V5-V6 leads.
D. High R wave in aVL and deep S in III, and aVF-leads.
E. Deep S in lead I and pathological Q in lead III