Case 4 – Tutor Guide

Week 1: History and Examination of the Cardiovascular System

Week 2: Performing ECGs

Clinical Skills Teaching

Year 1 Medical Students MB BCh

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Contents

Introduction to workshop .............................................................................................. 3

Introduction to C21 Clinical Skills Curriculum ................................................................ 4

Providing feedback to students ..................................................................................... 5

Background – Case 4 ...................................................................................................... 6

More specific Clinical Skills Learning Outcomes ............................................................ 6

Week 1 – History and Examination of the Cardiovascular System ........................... 7

Suggested Workshop Structure – Guidance for Tutors .................................................. 8

Further Information and Teaching Suggestions ............................................................. 9

Week 2 – Performing ECGs ................................................................................... 12

Suggested Workshop Structure – Guidance for Tutors ................................................ 13

ECG Relevant Information ............................................................................................ 15

Appendix A - The Calgary-Cambridge Guide ................................................................ 16

Appendix B - Generic Guide to History Taking ............................................................. 17

Appendix C – Guide to the Examination of the Cardiovascular System ...................... 18

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Introduction to workshop Welcome! Thank you for agreeing to help with this teaching.

These workshops occurs in the fourth case of Year 1. Prior to this case students have been introduced and had limited opportunities to practice the skills required for history taking. They have also been introduced to the following system based physical examinations and procedural skills:

Physical Examinations Procedural Skills

Musculoskeletal System – Knees & GALs Intramuscular & Subcutaneous Injections

Gastrointestinal System Urinalysis, Pregnancy Tests & Swab Taking

The focus for all these sessions is to introduce the students to the particular tasks and give them an opportunity to practice.

The students will have further opportunities to practice most of these skills in timetabled sessions in Year 2. They also can attend the Self Directed Learning area in the Clinical Skills Centre to practice the skills further.

This teaching session is delivered in parallel across the four centres used for year 1 and Year 2 clinical skills teaching – Merthyr, Newport, Bridgend and Cardiff.

Each centre may adapt the session to suit their own practical arrangements but it is important that all students get the same core teaching.

This teaching session is formatively assessed – this means that attendance is compulsory and students should get feedback whenever possible on their performance. If tutors are concerned that a student is not engaging with the session or is performing particularly poorly please inform the undergraduate manager or Paul Kinnersley (see below).

There is a formal assessment of the students’ clinical skills including their history and examination skills at the end of Year 2.

Students have access through the Learning Central (Blackboard) to a range of e-tutorials which are used as preparation for the practical sessions. These e-tutorials should be read by tutors in conjunction with this teaching plan. Students also have access to, for this session, a ‘Guide to examining the Cardiovascular System’. The general link to the Tutors Resource Site is http://blogs.cardiff.ac.uk/clinicalskillscentre/. Direct hyperlinks to each e-tutorial are also provided within this teaching plan.

If you have questions about this teaching please contact Paul Kinnersley, Director of Clinical Skills, kinnersley@cf.ac.uk or Sian Williams, Lead for Procedural skills teaching williamsse17@cf.ac.uk

Thank you again for your participation. The Clinical Skills and Simulation Team

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Introduction to C21 Clinical Skills Curriculum

The aim of C21 early clinical learning is that students learn to integrate their clinical, basic, behavioural and social sciences whilst exploring patients’ experiences of illness. It also seeks to help the student gain competence in history taking and in conducting physical examinations, whilst learning clinical reasoning and decision making skills. Good consultation skills lie at the heart of healthcare and as such students will be taught how to consult effectively from the beginning of the C21 course. Core skills are essential and may be learnt and developed through experiential learning, in order that students become equipped with a core set of skills to enable them to progress and master more complex consultations during their careers.

Through meeting real patients from the earliest stages of their undergraduate course and learning about the experiences of illness, we want students to develop a patient-centred approach to clinical practice and develop professional attitudes towards patients and colleagues.

The process of learning clinical skills:

In Phase 1 B students spend 1 day each week on Community Based Learning Placements (half the day) and learning clinical skills (half the day). During their Community Based Learning placements, students will rotate through a range of activities – visiting patients in their own home, visiting community physio clinics and see patients in GP surgeries so they meet real patients in a variety of settings which will ‘bring to life’ and contextualise their case-based learning and give them the opportunity to witness the effect of social environment on health and healthcare. They will also develop and learn transferable skills and informed professional attitudes, through contact with a multi-professional cohort of teachers.

Clinical skills teaching in Phase 1B consists of seven history and examination teaching sessions, three procedural teaching sessions, one session on assessing respiratory function and one on examining the eyes and ears.

Please note – the clinical skills teaching session are matched with Community based teaching sessions (students will do clinical skills in the morning and Community based learning in the afternoon or vice versa). There is overlap between these teaching sessions – see individual lesson plans – in the afternoon sessions please remember to ask students what they have done already in the morning so we can build on their prior learning.

Practise clinical skills in ‘real-life’

clinical setting

Practise clinical skills in controlled

clinical setting

Learn clinical skill in class room

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Providing feedback to students A key part of Clinical Skills teaching is providing feedback to students on their performance. To help learning, feedback needs to be objective and aligned with what the student is trying to achieve (their learning agenda or their individual learning needs). Early in the course students find it difficult to identify individual learning needs because they simply feel they need to learn everything – however it can still be helpful to start with this approach.

There are generally 2 agendas for feedback in the workshops and the tutor should seek to incorporate both:

What do the students feel they want/need to learn?

What do we want to teach them?

Where possible, feedback should be:

S - Specific, Significant, Stretching M - Measurable, Meaningful, Motivational A - Agreed upon, Attainable, Achievable, Acceptable, Action-oriented R - Realistic, Relevant, Reasonable, Rewarding, Results-oriented T - Time-based, Timely, Tangible, Trackable

The way in which we give feedback can directly influence how the students respond to the learning experience, and so if we are to nurture them, we need to do this in a supportive, safe fashion.

Review learner’s original agenda and encourage self-feedback from student

Provide constructive, timely feedback based on observations from tutor

Encourage supportive input from other students to solve problems

Re rehearsal of new skills, either by the individual, or by subsequent students incorporating lessons learnt earlier in workshop through observation of their peers.

– Ask the student ‘How did that go?’ – Link this to the students own agenda – Ask the student ‘What could be improved?’ – Open discussion to the other things for them to improve/ focus upon

Struggling students

It is important that students who struggle with their clinical skills for whatever reason are identified early. If a student in your group raises concerns, please take a little time at the end of the session to clarify how the student felt the session went. Some may just be nervous or unfamiliar with the teaching methods used. However, we routinely offer, all students who need them, remedial sessions – but we want to target these at those who need them most and need your help to identify these students. Tutors are therefore encouraged to be proactive about identifying students who they feel might benefit from such extra support, and pass their details to Jo Sloan (sloanjm@cf.ac.uk), so that students can be contacted at the appropriate time. If you have major concerns about a student’s behaviour please discuss your concerns with them if appropriate AND send a report to Paul Kinnersley (kinnersley@cf.ac.uk).

All students will be informed that you may raise your concerns with them and that this is meant to be helpful rather than to be seen as criticism.

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Background – Case 4 Brief summary (adapted from the Case Facilitator’s guide)

The patient in this case presents with symptoms of ischaemic heart disease. The presentation in week 1 is with symptoms of stable angina. The intention in week 1 is to introduce the students to concept of stable atheromatous coronary disease and to guide them in their learning about the scientific, clinical and sociological basis for this. In week 2, the case develops further with the patient presenting with symptoms of an acute coronary syndrome. The intention in week 2 is to introduce the students to the concept of unstable atheromatous coronary disease and to guide the students in their learning about the differences in the scientific basis for stable and unstable coronary disease. This will lead the students to understand the concepts and rationale that underpin the different management strategies of these conditions.

In the case fortnight students will get anatomy and physiology teaching relevant to the cardiovascular system and also make community visits to patients in their own homes and see patients with cardiac problems in GP surgeries. Whenever possible it is helpful if tutors help students connect together the various elements of their learning within the case.

The Higher Level Clinical Skills Learning Outcomes for the Case are:

Practice Outcomes

H1. Perform a focussed cardiovascular history H2. Perform a focussed cardiovascular examination

For practical convenience it is easiest to split the two Clinical Skills sessions in this case into one case focussed on the Cardiovascular History and Examination and one on performing ECGs.

More specific Clinical Skills Learning Outcomes

Identify the common symptoms patients with cardiovascular disorders present with

Demonstrate the key communication skills for gathering information about cardiovascular problems from patients and ensuring that they have an accurate understanding of the reasons why the patient is seeking medical help including key symptoms and their chronology, relevant past medical and medication history, and the patient’s social circumstances where these impact upon health and the effects of the illness on the patient’s life

Demonstrate the main features of the cardiovascular examination including performing an ECG

Demonstrate the ability to organise the information gathered from a patient and identify relevant diagnostic hypotheses for common cardiovascular problems using the diagnostic sieve as a framework

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Week 1 – History and Examination of the Cardiovascular System

Overall Session Aim (3 Hours)

Students will learn the skills required to take a history from a patient with cardiovascular symptoms – for example chest pain or shortness of breath. They should also develop their understanding of the impact of cardiovascular disease both on the individual, their family and society and consider how any negative impacts can be reduced.

Intended learning outcomes

By the end of this workshop the students should be able to:

Identify the common symptoms which suggest Cardiovascular Diseases.

Practise and perform the consultation skills for gathering information about cardiovascular problems from patients to ensure that they have an accurate understanding of why the patient is seeking medical help including:

- Key symptoms & their chronology, - Relevant past medical & medication history, - Patient’s social circumstances where these impact upon health and the effects of the

illness on the patient’s life

Demonstrate the ability to organise the information gathered from a patient and identify relevant

diagnostic hypotheses for common musculoskeletal problems using the diagnostic sieve as a framework

Practice and perform the Cardiovascular Examination

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Suggested Workshop Structure – Guidance for Tutors

Each centre may adapt the session to suit their own practical arrangements but it is important that all students get the core teaching addressing the learning outcomes above.

History and Examination of the Cardiovascular System

Resources

For 12-16 students 2 tutors 2 rooms For 16-30 students 3-4 tutors 3-4 rooms Actors or expert patients to provide histories and to be examined Suggested histories – see later in guide Couches/stethoscopes

Time Activity

20 mins Introduction to session – Common symptoms and signs of Cardiovascular Diseases Large Group discussion Identify the symptoms which suggest Cardiovascular disorders Differentiating different types of chest pain Consider impact of cardiovascular illness on the patient Consider how to organise information gathered and begin generating diagnostic hypotheses

80 mins Split into groups of 7-8 students Consulting with patients: 4 x 20 mins per patient

20 mins Tea break

50 mins Continue in smaller groups Physical examination of Cardiovascular system Demonstration and student practice

10 mins Conclusion and final discussion

Additional Resources

Geeky Medics Guide - Cardiovascular System: http://geekymedics.com/cardiovascular-examination-2/

Guide to the Examination of the Cardiovascular System – See Appendix C

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Further Information and Teaching Suggestions

A typical History and Examination teaching session

The focus of the history and examination teaching is getting the students to start to understand the process of gathering information from patients and processing this to form differential diagnoses.

The main sources of information available to doctors are:

(Thanks to Dr Tom Hughes for this diagram)

The focus in the first year will be equipping the students to gather accurate information from patients – the story and the examination. Later teaching will bring in pictures and numbers (though of course if appropriate it can be touched on earlier).

The teaching is organised as being about ‘the Gastro-intestinal history and examination’ – this is for practical reasons and to integrate it with other learning – these particular focussed history and examination skills can be considered to be ‘routines’ that doctors use if they think a patient has symptoms suggestive of a particular system problem. BUT it should be remembered that patients present with symptoms and doctors work with these to arrive at diagnoses (not from disease to symptoms as described in many textbooks). So doctors need to be able to take ‘generic’ histories which are flexible to the patient’s symptoms.

As well as gathering information about the main features of the disease, to enable them to make a diagnosis, doctors need to also gather information about the patient’s illness experience so that they can address the patient’s concerns and expectations and thus provide high quality care. Doctors treat people not diseases. By acquiring these skills, they will become more effective `history takers’ (and also be better at explaining illnesses and treatments). Clearly some students are naturally more competent at communicating than others but all students need to be aware of the skills required for good communication and have opportunities to practise these.

General principles:

We want to work from symptoms to diagnoses

To conduct good consultations students need to consider the ‘content’ – what you say – and the ‘process’ – how you say it – see above

Students should be encouraged to process the data they gather as they go along – this is automatic for experienced clinicians but not for new students – so for example the tutor might stop the student after they have gathered only one or two pieces of information from the patient and ask them what they are thinking. So students should:

The (his)story – from the patient, relatives or others

The Examination Pictures (x-rays or

other images)

Numbers (results of blood and other

tests)

Listen to the patient

Think Listen some

more Ask questions Think Think

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Students need to learn about ‘What’ information they should gather and also ‘How’ to best gather this information

For this we use the Calgary Cambridge Guide – Appendix A (page 16) – this provides an overall structure to the consultation and identifies which tasks need to occur where. It is also useful to organise the skills required for different tasks. In addition we have produced a Generic Guide to history taking – Appendix B (page 17) – which suggest both the Content (What information to gather) and the Process (how to gather this information). Whenever possible tutors should refer to these diagrams – copies of which will be available to students through Learning Central.

Students should use summaries frequently – ‘so you have had chest pain for 3 days and you are worried it could be lung cancer’ – so that they check they have the facts right, they process the information internally and they demonstrate listening to the patients

At the end of the history the student should have some diagnostic hypotheses – which may be as simple as a ‘problem with the GI system’!

Physical Examinations

To start with students should be performing their examinations to learn the routine of the knee or abdominal examination. They also need to become familiar with the ‘normal’ exam so they can recognise abnormal findings. Different teaching centres can use actors or real patients for this teaching. However sometimes it can be frustrating for students examining ‘normal’ people and they are keen to see pathology – obviously slides of abnormalities can be used and also to make it more interesting and instructive for the students tutors can ask ‘what would you think if ..... for example - the patient was tender on the right side of the abdomen’.

Students should be pointed to the surgical sieve to help them think about possible diagnoses. There are various versions of this but a simple version – for year 1 students would be:

Congenital Acquired - Trauma Infection

Inflammatory Neoplasm Degeneration Autoimmune

Environmental

Patient’s Ideas, Concerns, Expectations Thinking about history taking from patients with GI symptoms is a good opportunity to reinforce the practice of asking patients about their Ideas, Concerns and Expectations. I/C Patient’s ideas/concerns – these may be difficult to separate out and there is no real need to

– patients with abdominal pain are very likely to have a range of concerns some of which may include diagnoses such as cancer – and whether this is diagnostically likely or unlikely the concern still needs to be addressed. Students need to develop their own phrases for exploring ideas/concerns – what worries are on your mind? What have you been thinking? etc

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E Elicit expectations – it can be useful to elicit what patients are expecting to happen so that we can weave these expectations into our management – ‘Yes that’s right I’m sure we need to do some further tests…’ ‘although you said you thought you might need a whole body MRI there are some reasons why that wouldn’t be the best thing to do right now…’. Again students need to work out good phrases – saying ‘What do you expect us to do about this?’ doesn’t usually work but perhaps ‘Were you thinking we would do some further tests?’ might be more appropriate.

We warn the students that they may see and be taught slightly different approaches to history taking and to the physical examination by different people

Suggested patient scenarios – for actors or expert patients can be provided by Paul Kinnersley

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Week 2 – Performing ECGs Overall Session Aim (3 Hours)

The aim of this session is to produce a technically accurate, artefact free 12 lead ECG in accordance with AHA/ SCST guidelines. It is also for the student to be able to recognise the basic components of the ECG.

Intended learning outcomes

By the end of this workshop the students should be able to:

Recognise the anatomy of the conduction system of the heart.

Identify the waveforms of the cardiac cycle, as seen on the ECG.

Calculate the heart rate from the ECG.

Outline the equipment and specifications required for recording a 12 lead ECG.

State and demonstrate the anatomical positions for electrode placement.

Recognise and minimise interference patterns on an ECG.

Identify Einthoven’s Triangle, and its uses in practical electrocardiography.

Produce a technically accurate ECG.

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Suggested Workshop Structure – Guidance for Tutors

Each centre may adapt the session to suit their own practical arrangements but it is important that all students get the core teaching addressing the learning outcomes above.

Taught Session Time: 180 minutes

Session Progression Additional Resources

Introduction to ECG – whole group in Lecture Room

4 minutes Introduction Welcome and introduction of tutors/team Housekeeping

Housekeeping Briefing

3 minutes Discussion Whole group – Assessing prior knowledge and misconceptions

3 minutes Learning Aims and objectives Whole group – What are we setting out to achieve?

PowerPoint presentation

Whole group – Lecture room

15 minutes Introduction What is an ECG? Recap on the conduction system. Depolarisation and repolarisation.

PowerPoint presentation. Label the conduction system diagram. Depolarisation & repolarisation handouts

10 minutes Development Components of the ECG

Components of the ECG handout

10 minutes Development Current SCST guidelines for a 12 lead ECG. Einthoven’s triangle, recording procedure and electrode positioning

Positions diagram

15 minutes Development Sinus Rhythm, ST Elevation and Heart Block (case link)

ECG examples

Coffee Break – 30 minutes

ECG practice session - Split into smaller teaching groups

80 minutes Practical Demonstration by tutors performing a 12 lead ECG. Students working in pairs locate accurate electrode positions and perform a 12 lead ECG under supervision. Tutor to check placement of leads for accuracy.

Equipment packs ECG machine 12 lead ECG examples Bed, Pillow, Bed roll, ECG machine, model patient, ECG electrodes, skin preparation

7 minutes Recapitulation and Questions

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Conclude teaching session, student question time

3 minutes Evaluation Students to complete an evaluation

All student paperwork goes into appropriate box

Additional Resources

More information about this session can be found on the Clinical Skills Resource site for tutors. The link to the module is:

http://blogs.cardiff.ac.uk/clinicalskillscentre/

All resources required for this session are downloadable from the above link. Please find under the tab ‘Session Plans & Resources’ then click on ‘Year 1’, ‘Phase 1B’.

Students are asked to view an ECG practical e-tutorial prior to the session. Please find the ECG tutorial within the list of e-modules on the resource site or simply click on the link below.

ECG - A practical guide

Please Note:

The tutorial linked above is also available for students on Learning Central. Students have already received a briefing document asking them to look through this prior to attending the practical session.

In addition, a PowerPoint presentation prepared by the ECG team delivering the session at UHW is available on the CU tutor resource site. (This particular tutorial will be made available to students after the teaching has taken place). It is also provided here:

http://blogs.cardiff.ac.uk/clinicalskillscentre/cardiovascular-2/

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ECG Relevant Information

An ECG is a transthoracic interpretation of the electrical activity of the heart. A typical ECG tracing of the cardiac cycle (heartbeat) consists of a P wave, QRS complex, T wave and sometimes a U wave. William Einthoven chose the letters P,Q,R, S, T to identify the tracing.

The heart is influenced by the autonomic nervous system which can increase or decrease the heart rate in line with the requirements of the body. However, due to an intrinsic regulating system, called the conduction system it is possible for the heart to go on beating without any direct stimulus from the nervous system.

This system is composed of specialised muscle tissue that generates and distributes the conduction that causes contraction of the cardiac muscle. These tissues are found in the sinus (or sinoatrial) node, atrioventricular node, bundle of His, bundle branches, and conduction myofibres.

When stimulated by electrical activity, muscle fibres contract and produce motion. In the heart, this electrical activity is referred to as depolarisation. The contraction causes the blood to be pumped around the body.

Relaxation of the heart muscle is caused by electrical repolarisation.

Assessment

For the purposes of this workshop, students will be assessed on a formative basis. This will occur through observation and feedback on the student performance with the aim of encouraging further practice and improvement. Throughout the session it is proposed that frequent questions should be posed to the students, encouraging each student as the session progresses. An assessment sheet is provided, on which the tutor is asked to indicate the level of competency/engagement in the practical component. There is also room for ‘comments’ regarding student performance if required.

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Appendix A - The Calgary-Cambridge Guide

The Calgary-Cambridge Guide gives a generic structure for the tasks of any consultation

Building

the

relationship

Using appropriate

non- verbal

behaviour

Developing rapport

Involving the patient

Initiating the Session

Gathering Information

Physical Examination

Explaining & Planning

Closing the Session

Providing

structure

Making

organisation overt

Attending to flow

THE ENHANCED CALGARY-CAMBRIDGE GUIDE TO THE MEDICAL INTERVIEWJurtz SM, Silverman JD, Benson J & Draper J. (2003)

Marrying Content & Process in Clinical Method Teaching: Enhancing the Calgary-Cambridge Guides.

Academic Medicine

Preparation

Establishing initial rapport

Identifying the reason(s) for the Consultation

Exploration of the patient’s problems to

discover the:

Biomedical perspective

patient’s perspective

Background information- context

Providing the correct amount & type of

information

Aiding accurate recall & understanding

Achieving a shared understanding

incorporating the patient’s illness framework

Planning: shared decision making

Ensuring appropriate point of closure

Forward planning

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Appendix B - Generic Guide to History Taking

Content Process (suggested not prescriptive)

Getting off to a good start Inform patient of name Check patient’s identity Consent to consultation

Hello, I’m XXXXX YYYYY, I’m a first year medical student It’s Mrs Roberts isn’t it? Would it be alright if I had a talk to you before you see the doctor?

The presenting complaint WWQQAA (or SOCRATES) Where Site Radiation When Frequency/periodicity Duration Quality Character Quantity Severity Aggravating and alleviating factors Associated (other) symptoms Patient’s perspective ICEE Ideas Concerns Expectations Effects on life General health Systematic Review PMH Drug History Allergies Physical Exam if appropriate Note: ICEE needs flexible approach as to timing within consultation – see process

Open to close cone Open questions What seems to be the problem? Can you tell me some more? Anything else? Summarise So to summarise…… Further enquiry about main problem Tell me some more about this chest pain Shift to closed (focussed) questions Now can I ask you some specific questions Was there any blood in the vomit? What makes the pain worse etc? Exploring ICEE What’s have you been thinking could be causing this? What’s your main worry about all this? Follow up worries – if patient says ‘and when I started vomiting I was really worried…’ respond with ‘What thoughts were going through your mind?’ or similar

Are you otherwise well? Have you had any serious illness in the past? Have you had any operations? Have you had diabetes Additional empathic statements To build relationship and provide support – ‘That must be very difficult for you’ (about a chronic problem); ‘So you’ve been really sick’ (more acute problem)

Good ending Inform them of next stages in care

Thank patient ‘I’m going to report to the consultant and then she will come and see you with me’

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Appendix C – Guide to the Examination of the Cardiovascular System

A copy of this guide is available to students through Learning Central

Please note: as with other examinations, different clinicians will perform these examinations in slightly different ways – and different resources (Macleod’s Clinical Examination, www.geekymedics.com etc) may describe the examination slightly differently. Students need to establish their own routine for performing these examination and this Guide is intended to help them do this. Students do NOT fail ISCEs/OSCEs if they do the examination slightly differently to as described here. Feedback is welcome – please send to Paul Kinnersley (kinnersley@cf.ac.uk) At the start of every examination Clean hands Introduce yourself to the patient Explain what you are going to do and check if patient in any pain Expose the patient appropriately preserving dignity Outline of Cardiovascular Examination Observe the patient’s general condition – do they look ill? Short of breath at rest? In pain? On oxygen? Scars? Cyanosis? Position and expose chest appropriately – at approx. 45 degrees Examine hands and nails – peripheral cyanosis? Poorly perfused peripheries? Clubbing? – Chronic hypoxia congenital heart disease; Splinter haemorrhages? – Infective endocarditis but also trauma Assess radial pulse for rate, rhythm – normal pulse 60-80 beats per minute, regular/irregular? – irregularly irregular probably atrial fibrillation; regular with ectopics? Feel other pulse for radio-radial delay. Consider checking for a collapsing pulse – check the patient doesn’t have any problems with their shoulder – grasp their wrist so their radial pulse is covered by the palm of your hand – raise the patients arm to above head height – a collapsing pulse will present as tapping against your palm – this signifies aortic incompetence (v rare) Measure blood pressure Examine eyes – anaemia, xanthelasma, corneal arcus, Mouth – central cyanosis, dentition (poor dentition related to subacute bacterial endocarditis) Neck – feel carotid pulse for character - normal? weak? – shock (would expect tachycardia), bounding ? – emotion, fever, pregnancy, anaemia; slow rising – severe aortic stenosis, collapsing - aortic regurgitation Assess JVP – check patient is at angle of approx. 45 degrees with their neck relaxed; look across neck between two head of sternocleidomastoid for a pulsation – check whether pulse is venous or arterial – venous will be non palpable, will have double impulse, will rise with abdominal pressure over liver. Normal JVP is less than 4 cms vertically above the sternal angle – this means often not visible in normal patients. For practice can ask patient to lie down flatter to visualise JVP but this makes exact measurement unreliable.

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Causes of raised JVP: right ventricular failure, tricuspid stenosis, tricuspid regurgitation, superior vena cava obstruction, PE, fluid overload. Inspect chest (praecordium) – scars - sternotomy suggests cardiac surgery, pacemakers - usually left side of upper chest, visible apex beat? Palpate praecordium

apex beat – should be in fifth intercostal space, mid clavicular line

sternal heave – forceful ventricular contraction due to ventricular hypertrophy

thrills – palpable vibration from severe murmur so feel pulse to work out if systolic or diastolic

Auscultate heart – listen at apex, base, pulmonary and aortic regions Listen to heart sounds – can help to gently feel carotid pulse at same time

First heart sound – mitral valve closing

Second heart sound – aortic and pulmonary valves closing

If there is a murmur try to work out if systolic or diastolic Systolic murmurs Aortic stenosis – ejection systolic murmur heard at apex, right sternal edge and radiates to neck Mitral regurgitation – pansystolic murmur best heard at apex and radiates to axilla Diastolic murmurs – generally more difficult to hear Mitral stenosis – best with patient rolled on to left side and heard at apex with the bell of stethoscope Aortic regurgitation – best with patient sitting up, leaning forward and breathing out, left sternal edge with diaphragm Listen to lung bases – pulmonary oedema from cardiac failure? Examine sacrum/ankles for peripheral oedema Thank patient Summarise findings