december 2017 version 2 - usjpmedical.sjp.ac.lk/downloads/module-books/phase-i/4...

December 2017 Version 2.0

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Cardiovascular Module – Phase 1

Faculty of Medical Sciences

University of Sri Jayewardenepura


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Introduction

Welcome to the Cardiovascular Module! This is a very exciting module that

will be very important to your future work as doctors. The module has been

designed in a novel way that will make your learning both interesting and

productive.

During this module, you will be encouraged to learn the structure and function

of the cardiovascular system in an integrated manner: this means that what was

previously categorized into subjects such as Anatomy, Physiology and

Biochemistry, will be learnt and assessed together (horizontal integration). We

will also help you learn the basic sciences in a way that is relevant to their

clinical applications (vertical integration). We are taking this approach in order

to prepare you better for your future work as doctors, where patients will come

to you with clinical problems, which are not categorized by discipline names.

In order to help you learn in this integrated manner, we have arranged the

learning of basic sciences around a few key health-related situations (real life

situations), which you are likely to encounter as first year medical students. You

will be expected to think about these scenarios and complete worksheets. You

may do this individually or with your colleagues. It will also help to focus your

attention on what you need to gain from the lectures, practicals and tutorials

that have been scheduled during this module.

Module Committee

Dr. C. Hewage(Chairperson,Department of Physiology)

Dr. S. Shiyanth(Convener, Department of Anatomy)

Senior Prof. H. Peiris (Department of Biochemistry)

Dr. Varuni Tennakoon (Department of Anatomy)

Dr. Sajith Edirisinghe (Department of Anatomy)

Dr. Chandimani Undugodage (Department of Physiology)

Dr. Dinesha Sudusinghe (Department of Physiology)

Dr. P.P.R. Perera (Department of Biochemistry)


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General Objectives

At the end of the cardiovascular module, the student should be able to:

1. explain the normal structure of the heart, including its musculature,

coverings, blood supply, nerve supply and its development.

2. explain the surrounding thoracic structures, surface marking of heart and

great vessels

3. explain the normal function of the cardiovascular system by learning and

applying the relevant basic sciences.

4. apply the above knowledge to a few common real life situations

(Hypertension, Myocardial Infarction, Shock, Congenital heart disease ) to

explain how the anatomy, physiology and biochemistry are altered in the

given situations.


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Main Content Areas

Main Content Area Lectures

(Hours)

Practical/Dissections

No. of (3hrs)

sessions

Tutorials/SGD

No. of (2hrs) sessions

1. Contents of the mediastinum and structure of the heart

(Anatomy)

06 06 02

2.Arterial & venous system and embryology of the heart

(Anatomy)

03 02 01

3.Posterior mediastinum (Anatomy) 01 02 01

4.Cardiac conduction system and ECG (Anatomy, Physiology) 00,03 01,01 -

5.Cardiac cycle, heart sounds, arterial & venous pulses and

cardiac output (Physiology)

04 - 01

6.Structure of blood vessels, haemodynamics of the circulation

and normal blood pressure (Anatomy, Physiology)

01,02 01,01 00,01

7.Cardio vascular system regulation (Physiology) 02 - 01

8.Coronary circulation and regulation (Physiology,

Biochemistry)

02,02 - -

9.Cardiovascular adjustments during exercise (Physiology) 02 01 -

10.Pathophysiology of shock, hypertension, heart failure and

syncope (Physiology) 07 - 01

11. Cardio-pulmonary resuscitation (Physiology) - 01 -


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Real life situations

Real life situation 1: Myocardial Infraction

Real life situation 2: Hypertension

Real life situation 3: Shock

Real life situation 4: Congenital heart disease


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Cardiovascular Module – Phase I

A-Essential to know B- Good to know C- Nice to know

1. CONTENTS OF THE MEDIASTINUM AND STRUCTURE OF THE HEART

Intermediate Objectives Broad Content Areas Activity Duration Department

Define the mediastinum & its divisions

Describe the structures and their relationships in

superior mediastinum

Describe the contents of middle mediastinum

Describe the structure of the atria and ventricles

Divisions & contents of the

mediastinum(A)

Boundaries, structures at plane

through sternal angle:

arch of aorta, SVC, brachiocephalic

veins, carotid, subclavian and

brachiocephalic arteries,

ligamentumarteriosum, cardiac

plexus,phrenic and vagus nerves.(A)

Pericardium

- Fibrous and serous

- Oblique and transverse sinus(A)

Openings of the SVC & IVC into

the right atrium, right

atrioventricular valve, coronary

sinus, crista terminalis,

musculipectinati, interatrial septum,

fossa ovalis & limbus, Value of the

IVC and coronary sinus.(A)

Openings of the right ventricle,

Lecture

Dissection &

prosected

specimens

Tutorial

Dissection &

prosected

specimens

Dissection &

prosected

specimens

Tutorial

Lecture

1 hr

5 hrs

2 hrs

3 hrs

6 hrs

2 hrs

2 hrs

Anatomy

Anatomy

Anatomy

Anatomy

Anatomy

Anatomy

Anatomy


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1. CONTENTS OF THE MEDIASTINUM AND STRUCTURE OF THE HEART(continued)


Describe the major vessels from the heart

Describe the nerve supply of the heart

Describe the histology of cardiac muscle

Surface mark the cardiac borders, heart valves,

main arteries of the heart and the entrance of

superior and inferior vena cava to the heart

atrioventricular valve & its opening,

pulmonary valve & its opening,

trabeculae carneae, chordae

tendinae, papillary muscles & the

conus arteriosus.(A)

Opening of the left ventricle & the

features of their valves, papillary

muscles & the muscular &

membranous parts of the

interventricular septum(A)

Internal features of left atrium & its

openings(A)

Describe the branches of pulmonary

trunk and distribution of left and

right pulmonary arteries, aorta,

ascending aorta(A)

Sympathetic supply,

parasympathetic supply and cardiac

plexus(A)

Microscopy of cardiac muscle (A)

Surface marking

- Cardiac borders

Dissection &

prosected

specimens

Lecture

Lecture

Lecture

3 hrs

1 hr

1 hr

1 hr

Anatomy

Anatomy

Anatomy

Anatomy

Anatomy


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1. CONTENTS OF THE MEDIASTINUM AND STRUCTURE OF THE HEART(continued)


Interpret the imaging anatomy of the heart

- Atrioventricular, pulmonary and

aortic valves

- Origin of aorta, brachiocephalic

trunk,subclavian and common

carotid arteries, pulmonary arteries

- Entrance of superior and inferior

vena cava (A)

Cardiac borders, great vessels and

cardiac chambers (A)

Démonstrations

1 hr

Anatomy


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2. ARTERIAL & VENOUS SYSTEM AND EMBRYOLOGY OF THE HEART


Describe the arterial supply & venous drainage of

the heart

Describe the development of the heart

Describe the development of sinus venosus, atria,

ventricles and intracardiac septa and associated

congenital heart defects

Describe the development of the atrioventricular,

aortic and pulmonary valves and associated

congenital heart defects

Outline the development of the arterial & venous

system and associated congenital heart defects

Coronary arteries

Coronary sinus & great cardiac vein

(A)

Embryology of the heart(A)

Right and left atria

Right and left ventricles

Inter-atrial & inter-ventricular septa

ASD, VSD, Fallot’s tetralogy (A)

Atrioventricular valves aortic &

pulmonary valves (B)

PDA, Coarctation of aorta (A)

Dissection

Lecture

Lecture

Tutorial

Prosected

specimens

3 hrs

1 hr

2 hrs

2 hrs

3 hrs

Anatomy

Anatomy

Anatomy

Anatomy

Anatomy


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3. POSTERIOR MEDIASTINUM


Describe the boundaries and contents of the

posterior mediastinum.

Describe the course and relation of thoracic aorta

Describe course and relation of thoracic duct

Describe the course and relations of oesophagus.

(Cervical and abdominal part of oesophagus will be

covered in Head & Neck and GIT module

respectively)

Describe the azygos system of veins.

Describe the sympathetic trunk and splanchnic

nerves

Boundaries

Contents – thoracic aorta, lymphatic

system, thoracic duct, oesophagus,

azygos system of veins and

sympathetic trunk (A)

Course, branches(A)

Course, relations(A)

Relations, blood supply(A)

Course, draining structures(A)

Relations of sympathetic trunk

Course of splanchnic nerves (B)

Dissection

Dissection &

prosected

specimens

Lecture

Tutorial

3 hrs

3 hrs

1 hr

2 hrs

Anatomy

Anatomy

Anatomy

Anatomy


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4. CARDIAC CONDUCTION SYSTEM AND ECG


Describe the conduction system of the heart and

spread of cardiac excitation within the heart.

Explain the genesis of pacemaker potentials at the

SA node

Identify the factors affecting the discharge from the

SA node

Draw a diagram of the action potential of cardiac

muscle.

Explain the genesis of the ECG wave in relation to

its cardiac electrophysiology

Place the unipolar and bipolar leads in an adult &

describe the appearance of the normal ECG

recording from lead II and explain the waves. .

Calculate heart rate, PR interval and determine the

mean electrical axis.

Position of the SA node, AV node,

AV bundle, bundle branches and

their significance. (A)

Significance of innervation of the

heart (A)

Electrical activity of the heart (A)

Genesis of ECG wave (A)

Placing of electrodes and

description normal ECG (A)

Calculation of

- Heart rate (A)

- PR interval(A)

- Mean electrical axis(B)

Dissection

Lecture

Lecture

Practical/

demonstration

on ECG

Practical/Skills

lab

3 hrs

1 hr

1 hr

3 hrs

Anatomy

Physiology

Physiology

Physiology

Physiology


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4. CARDIAC CONDUCTION SYSTEM AND ECG (continued)


Outline the uses of ECG

Diagnostic uses of ECG - identify

- Abnormally slow/ rapid/

irregular rhythm

- Abnormal spread of excitation

- Changes in cardiac size

- Ischemic damage to heart

- Hypo and hyperkaleamia

(B)

Lecture

1 hr Physiology

5. CARDIAC CYCLE, HEART SOUNDS, ARTERIAL & VENOUS PULSES AND CARDIAC OUTPUT


Describe the light & electron microscopic features

of cardiac muscle

Describe the sequence of events that occur in the

heart during the cardiac cycle

Illustrate the pressure changes that occur in a single

cardiac cycle

Relate the genesis of arterial & jugular venous

pulses to underlying cardiac events & describe the

jugular venous pressure (JVP) and the value of

central venous pressure (CVP) measurement

Cardiac cycle - Mechanical events

(A)

Intra-atrial, intra-ventricular and

aortic - pressure changes(A)

Genesis of arterial and venous

pulses(A)

JVP/CVP(B)

Recall/Self

Study

Lecture

SGD

Lecture

2 hrs

2 hrs

1 hr

Anatomy

Physiology

Physiology

Physiology


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5. CARDIAC CYCLE, HEART SOUNDS, ARTERIAL & VENOUS PULSES AND CARDIAC OUTPUT

(continued)


Explain the mechanism of the production of heart

sounds

Describe the function of the heart valves and

genesis of murmurs & state the timing of the

murmurs produced by valvular defects &

congenital heart disease

Define cardiac output and state its relationship to

stroke volume and heart rate

List and explain the factors that regulate cardiac

output

Explain the principles of measuring the cardiac

output

State the changes in cardiac output in selected

conditions

Heart sounds (A)

Function of the heart valves

&murmurs (A)

Cardiac output – definition (CO)

(A)

Factors that regulate CO (A)

Principles of measuring CO (B)

Effect of selected conditions on CO

(B)

Lecture

1 hr

Physiology


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6. STRUCTURE OF BLOOD VESSELS, HAEMODYNAMICS OF THE CIRCULATION AND NORMAL BLOOD

PRESSURE


Describe the light & electron microscopic

features of the arterial & venous system

Describe the types of blood flow

Describe the relationship between flow,

pressure & resistance in the vascular system

Compare Windkessel vessels & resistance

vessels

Define systolic blood pressure, diastolic blood

pressure and mean arterial pressure.

List the methods available to measure the blood

pressure

Classification of arteries & veins

Features of 3 types of arteries and

veins

- Light microscopic(B)

- Electron microscopic (C)

Haemodynamics

- Types of blood flow(B)

Factors that affect blood flow (A)

Windkesselvs resistance vessels (C)

-Resistance -Pressure

-Volume -Flow

Definitions of arterial blood

pressure(A)

Methods of blood pressure

measurement(A)

Lecture

Practical

(Histology)

Lecture

SGD

Lecture

1 hr

3 hrs

1 hr

2 hrs

1 hr

Anatomy

Anatomy

Physiology

Physiology

Physiology


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6. STRUCTURE OF BLOOD VESSELS, HAEMODYNAMICS OF THE CIRCULATION AND NORMAL BLOOD

PRESSURE(continued)


Describe the physiological basis of measuring

blood pressure using a sphygmomanometer

List the physiological & pathological variations in

blood pressure

Perform a physical examination of the

cardiovascular system

Physiological principles of BP

measurement (A)

Variation of blood pressure (B)

- Physiological

- Pathological

Cardiovascular system examination

- Arterial and venous pulses,

blood pressure, heart sounds (A)

Practical

3 hrs

Physiology

7. CARDIO VASCULAR SYSTEM REGULATION


Explain the effects of altered blood flow

Describe the importance of regulation of

cardiovascular system and the factors affecting it

Importance of regulation

Factors involved

- Local mechanisms

o autoregulation,

o paracrine secretion

- Systemic mechanisms

o circulating substances

o neural mechanisms (A)

Lecture

SGD

2 hrs

2 hrs

Physiology

Physiology


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8. CORONARY CIRCULATION AND REGULATION


Describe the anatomy of the left and right coronary

arteries and their branches & describe venous

drainage of the heart

Describe areas of the myocardium supplied by

these arteries

Describe coronary blood flow in relation to the

cardiac cycle

Describe the regulation of the coronary blood flow

Describe the mechanism of atherosclerosis and the

factors affecting it

Describe the effects of coronary artery occlusion

and principles of diagnosis & management

Anatomy of coronary circulation

(CVS Gen. Obj. 2) (A)

Changes in coronary blood flow in

relation to cardiac cycle (A)

Regulation

- Chemical & neural factors that

affect coronary bloods flow (A)

Classification of hyperlipidaemia

Effects of oxidized LDL, Lp(a) and

homocysteine (A)

Ischaemia and Myocardial

infarction

Uses of ECG, plasma enzymes and

proteins (AST, LDH, CK,

troponins)in diagnosis of ischaemia

and myocardial infarction(A)

Selection of diagnostic tests

Physiological basis for treatment

modalities(B)

Recall

Lecture

Lecture

Lecture

1 hr

1 hr

2 hrs

Anatomy

Physiology

Biochemistry

Physiology/

Biochemistry


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9. CARDIOVASCULAR ADJUSTMENTS DURING EXERCISE


Changes in muscles during isometric / isotonic type

of exercise

Cardio – respiratory adjustments during isometric /

isotonic type of exercise

Perform tests to determine the function of the

autonomic system

Physiological changes in muscles

during isometric / isotonic type of

exercise (A)

Physiological adjustments in

athletes to increase exercise capacity

Beneficial effects of regular form of

exercise

Effect of cardio respiratory diseases

on exercise tolerance

(A)

Cardiopulmonary testing (A)

Lectures

Practical

2hrs

3 hrs

Physiology

Physiology

10. PATHOPHYSIOLOGY OF SHOCK, HYPERTENSION, HEART FAILURE AND SYNCOPE


Define shock

Describe the four major causes of shock and

explain giving examples the pathophysiology of

each one.

Explain the physiological basis of signs and

symptoms of different types of shock

Shock – definition (A)

Causes of shock with examples (A)

Physiological basis of clinical

features (A)

Lecture

3 hrs

Physiology


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10. PATHOPHYSIOLOGY OF SHOCK, HYPERTENSION, HEART FAILURE AND SYNCOPE(continued)


Describe the physiological basis of treatment of

each type of shock

Explain the short and long-term physiological

compensation of shock

Define heart failure

Explain the physiological basis of the common

clinical manifestations of heart failure

Describe the different types of heart failure

Describe the haemodynamic, neuroendocrine &

cellular changes that occur in heart failure

Describe the physiological basis of the treatment

principles in heart failure

Define syncope and list the causes of syncope

Physiological basis of treatment(B)

Physiological compensation(A)

Definition of heart failure(A)

Physiological basis

Common clinical manifestations

(A)

Types

- Left/right heart failure

- Systolic/diastolic HF

- Acute/chronic HF(A)

Haemodynamic, neuroendocrine &

cellular changes in heart failure(A)

Treatment principles(B)

Definition of Syncope(A)

Main causes(A)

Lecture

Lecture

2 hrs

1 hr

Physiology

Physiology


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10. PATHOPHYSIOLOGY OF SHOCK, HYPERTENSION, HEART FAILURE AND SYNCOPE(continued)


Explain the pathophysiological basis for the

occurrence of syncope in each of these cases

Explain the compensatory measures that maintain

the blood pressure on rising from supine positions

Define hypertension

List the causes of hypertension

Describe the pathophysiology of hypertension

Explain the physiological basis of the treatment

principles in hypertension

List the complications of hypertension (CVA, IHD

etc.)

Pathophysiological basis for

syncope (A)

Blood pressure regulation when

rising from supine position (A)

Hypertension – definition (A)

Causes (A)

Pathophysiology (A)

Treatment principles (B)

Complications (B)

Physiological basis of clinical

features, principles of treatment and

diagnosis of above abnormalities in

cardiovascular system (A)

Lecture

SGD

1 hr

2 hrs

Physiology

Physiology


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11. CARDIO- PULMONARY RESUSCITATION


Define cardiac arrest & cardio pulmonary

resuscitation

List the types and causes of cardiac arrest

Outline the components and stages of CPR

Perform basic life support accurately

Understand the basic principles of advanced life

support

Define cardiac arrest and CPR (A)

Types and causes of cardiac arrest

(A)

Airway, Breathing and Circulation

of resuscitation (A)

Anatomical considerations in

- Opening up the airway

- Establishing airway

- Establishing breathing and

circulation

- Maintaining breathing &

circulation

(A)

Establish A B C in advanced life

support (B)

Practical

3 hrs

Physiology


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Real life situation-1

Myocardial Infarction

Topic: Myocardial Infarction

Scenario:

You are a first year medical student. One evening, your friend from next door,

who is also a first year medical student, rushes to your home saying that his

father is ill. He asks you to come and help.

You find that your friend’s father is complaining of a severe chest pain. You

also notice that he is sweating, and he complains that he feels ‘vomitish’.

You and your friend are unsure of what to do, but from what you have heard,

you feel that the patient needs immediate medical attention. You calm the

patient, and arrange for him to be transported to the teaching hospital of your

medical faculty. The patient receives immediate treatment and undergoes a

number of investigations.

After a few days, your friend comes over to thank you, and says that the

diagnosis card indicated that his father had a ‘myocardial infarct’. He says that

he would like to know more about how to look after his father from now on, and

also wants to understand more about the disease. He asks whether you could

join him in finding out the relevant information.

You are keen to find out as much as possible to help your friend. You realize

that you already know a few things about ‘heart attacks’, but you also know that

you are unsure about many aspects. That evening, you decide to make a list of

what you already know, and the issues that you would like to find out more

about.

You then wonder how you can find out the necessary information. You are

aware that a number of lectures, practicals and tutorials are scheduled in your

medical course, and decide to look through your timetable to see whether they

may be useful. You realize that these will help you with only some of the

learning issues that you have listed above, but you decide to concentrate on

these only at this stage.

You decide to look for other sources of information that may be helpful, at a

later stage.


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Real life situation-2

Hypertension

Topic: Hypertension

Scenario:

Your uncle is thrilled to hear that you have entered the medical faculty. He

comes to you and says that now he can depend on you to measure his blood

pressure regularly, and provide necessary advice. You reluctantly tell him that

you are only a first year medical student, and that you are as yet unable to help

him. You advise him to continue visiting his regular doctor, but promise to start

helping him as soon as possible.

You are now keen to find out more about blood pressure, how the body controls

it normally, and what causes blood pressure to be high in some persons. You

decide to make a set of notes that will help you understand this condition better.

As a first step, you make a list of what you already know about blood pressure

and what more you would like to find out in order to understand this condition

better.

You are aware that a cardiovascular module is available in your medical course,

and eagerly await its commencement. You learn as much as possible about the

areas that you identified above, and complete your set of notes as far as

possible. You become aware that you can only address some of the areas at this

stage of your medical study, and decide that this is sufficient for now.

You carefully note down the areas that you want to learn about later in your

medical course.


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Real Life Situation-3

Shock

Topic: Shock

Scenario:

You are a first year medical student. On your way to the hostel after lectures

you see a group of people calling for help. When you go to the spot you see a

middle aged man lying on the road with a stab injury on the left lower aspect of

the chest. There is bleeding from the wound.

After a few minutes paramedics arrive at the scene and check his pulse and

blood pressure. His blood pressure was 90/60mmHg and pulse rate was 120

beats/min. The paramedics mention the “shock”. They elevate his legs and

insert two cannulae and start transfusion of intravenous fluids. The patient is

then rushed to the Kalubowila hospital.

Now you are interested in finding out what the paramedics meant by the term

“shock” and how it occurs. You know your CVS module is the next module.

Before the commencement of that module, you decide to list out what you

would like to learn about shock and related topics. You then proceed to make

some notes about “shock” with the help of reading material in the library and

the IT lab.


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Real Life Situation-4

Congenital heart disease

Topic: Congenital heart disease

Scenario:

You are a first year medical student. One of your neighbor visits your

home, with her 3 months old child seeking your help to know details in the

diagnosis card given at CSTH about her child’s health condition. On inquiry,

she further states that her child’s lips were turning to bluish colour gradually

over last two months. Child also experienced sudden loss of conscious attacks.

As you keenly went through the diagnosis card it further stated, that child was

diagnosed as having Tetralogy of Fallot.

Even though you didn’t start CVS module, you are interested in finding

out what the term “Tetralogy of Fallot” means and why the child turned into

blue. You know your CVS module is the next module. As you glance through

the contents of the CVS module, you found the Tetralogy of Fallot comes under

the congenital heart disease. You also got to be aware that a sound knowledge

in development of the heart is essential in better understanding. With the core

knowledge you had acquired in basic embryology, you proceed to learn about

the development of the heart with the help of lecture, text books and accepted

references using internet. (Please go to peer reviewed referenced sites)


26

Recommended readings

Note- Students are expected to read the latest edition

Anatomy

Cunningham's Manual of Practical Anatomy by G. J. Romanes

Clinical Anatomy – Applied Anatomy for students and Junior Doctors by

Harold Ellis Vishy Mahadevan

Grant’s Atlas of Anatomy by Anne M.R.Agur and Arthur F. Dalley

Human Embryology by Indebir Singh

Langman’s Medical Embryology by by Thomas W. Sadler

Wheater's Functional Histology: A Text and Colour Atlas by Barbara

Young, Geraldine O'Dowd and Phillip Woodford

Biochemistry Lecture notes on Clinical Chemistry – L.G. Whitby, A.F. Smith and I.W.

Percy-Robb

Clinical biochemistry by William Marshall, Marta Lapsley and Andrew Day

Physiology Ganong’s Review of Medical Physiology by Kim E. Barrett, Susan M.

Barman, Scott Boitano and Heddwen L. Brooks

Guyton and Hall Textbook of Medical Physiology by John E. Hall

Hutchison's Clinical Methods by Michael Glynn and William M. Drake

Pathophysiology of Disease: An Introduction to Clinical Medicine by Gary

D. Hammer and Stephen J. McPhee

Chapters on cardiovascular disorders,

Vascular disease & cardiovascular disorders: heart disease

Kumar & Clark’s Clinical Medicine by Parveen Kumar & Michael Clark

https://www.amazon.com/s/ref=dp_byline_sr_book_1?ie=UTF8&text=Thomas+W.+Sadler+PhD&search-alias=books&field-author=Thomas+W.+Sadler+PhD&sort=relevancerank

https://www.amazon.com/s/ref=dp_byline_sr_book_1?ie=UTF8&text=Barbara+Young+BSc++Med+Sci+%28Hons%29++PhD++MB++BChir++MRCP++FRCPA&search-alias=books&field-author=Barbara+Young+BSc++Med+Sci+%28Hons%29++PhD++MB++BChir++MRCP++FRCPA&sort=relevancerank

https://www.amazon.com/s/ref=dp_byline_sr_book_1?ie=UTF8&text=Barbara+Young+BSc++Med+Sci+%28Hons%29++PhD++MB++BChir++MRCP++FRCPA&search-alias=books&field-author=Barbara+Young+BSc++Med+Sci+%28Hons%29++PhD++MB++BChir++MRCP++FRCPA&sort=relevancerank

https://www.amazon.com/s/ref=dp_byline_sr_book_2?ie=UTF8&text=Geraldine+O%27Dowd+BSc+%28Hons%29++MBChB+%28Hons%29++FRCPath&search-alias=books&field-author=Geraldine+O%27Dowd+BSc+%28Hons%29++MBChB+%28Hons%29++FRCPath&sort=relevancerank

https://www.amazon.com/s/ref=dp_byline_sr_book_3?ie=UTF8&text=Phillip+Woodford+MB+BS++FRCPA&search-alias=books&field-author=Phillip+Woodford+MB+BS++FRCPA&sort=relevancerank

december 2017 version 2 - usjpmedical.sjp.ac.lk/downloads/module-books/phase-i/4...

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