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So the structure of today, we'll start with how to take a history. Um then the examination and then some quick SBA S um just a heads up, especially for the examination. I've put quite a lot of detail just to make quite a comprehensive powerpoint with everything on your imperial checklist and a bit more that they might expect from you, but that they, but they don't tell you um all your patients in year three are normal except neuro where they might fake some like weakness or loss of sensation. So just make sure to learn the steps and a normal examination and that should be enough signs and symptoms will benefit you in your conditions and maybe later on. Um but just having the steps down is the most important thing. So starting off with the history taking, here's your general structure. I'm sure you are with it. You have your intro, your presenting complaint, your history of your presenting complaint, and then you might perhaps do Socrates, then your systems review, which will cover in a bit more detail, your ice your past medical history, your drug history, your social history and your family history. So your structure might be slightly different and that's ok. I always find it easier to add systems review right after doing the history just so you don't forget. Um And yeah, we'll focus on systems review for now. So here are the symptoms you want to specifically ask about in a cardiac history. It's quite a busy slide, but the ones in red are the top five sort of absolute ones you don't want to miss. So just make sure you learn them and ask them in your history. So I've put some differentials here as well. Um As these are the conditions you want to be thinking of and ruling in and out in your head when you're asking these questions. So the first one is dizziness. So just asking them if they've been dizzy at all, um asking about presyncope or syncope, shortness of breath is quite important and if they do have shortness of breath, you might want to do a rest systems review as well. Um And then ask him if they've, if they've had a cough to sort of check for infection, um any nausea or sweating, chest pain, really important one. And you do Socrates for that as well. Um And then palpitations, claudication, peripheral edema and exercise tolerance. And these are the sort of questions that you wanna be asking as well, just that it's more patient friendly and you don't use any jargon. Um You might also wanna ask if they've had any recent fever, any cough or any abdo pain. And then as always end with your flaws. So ask about fever, lethargy, appetite change, weight loss and sweats. So here are some risk factors that you also might wanna cover in your history. So for heart disease, you've got non modifiable modifiable risk factors. So non modifiable things you can't change, for example, um being slightly older um your gender. So men are at a slightly higher risk of heart disease than your family history and then the patient themselves and their history of heart disease. Um And then you have some more modifiable risk factors. So you wanna know um if they smoke, if they've ever smoked, um and how many cigarettes are smoking a day you wanna ask about, you know, obesity, sedentary lifestyle, high cholesterol, high blood sugar, high BP. These are things that might give you clue as to what the diagnosis is. And yeah, just briefly touching on family history. It's quite important in a cardiac history, which is why I've included it here. Um Try your best to remember these and just ask about them in the family history. Um So you've got previous heart disease, stroke, diabetes, high cholesterol hypertension, asthma, and cardiac disease, pe and sudden deaths um with sudden deaths, try your best to approach it empathetically. Um Sometimes the patients can get quite, you know, distressed, obviously, when you're asking about family history. Um So just be careful with that one. Um This, I've pasted from some documents on in send, if you go to your year three examinations section on the Sunday, you can see all of these for all of the different examinations. Um And it just goes in detail of what presentations and conditions could come up essentially matching to your conditions. But um it's just quite useful cos there's only so many presentations they can ask you for example, like chest pain or palpitations. So it's worth just practicing those obviously a lot nearer to your ay um the time of that. So yeah, just going over now, the actual examination. So first step in any examination is you wanna wash your hands. It's an easy one to forget, but it is a point on the checklist. Um So definitely, you know, don't miss that one. Then you have your intro again, I've written quite a full one here just for you to look over in your own time afterwards. Um But yeah, just introduce yourself, gain consent, confirm patient identity, ensure they're exposed properly and the bed's at 45 degrees for cardio, then you wanna go in with your general inspection. So you wanna look from the end of the bed, just make it really obvious to the examiner that you're looking from the end of the bed. Um Have a good look around, you know, left, right top bottom everywhere. Just have a good look. Um Is the patient like how do they appear generally? Are they? Well, are they unwell? Do they look in pain? And then you wanna mention at least these two at the end when you're presenting. So if there were any ECG leads any medical paraphernalia, so basically any medical equipment, so things like oxygen, fluids, uh GTN spray, you wanna look for any signs of anemia. So any pallor, any scars, shortness of breath, sinuses, pallet edema. So just have a look out for um any of these things. And two is more than enough to mention at the end. So, moving on to hands and arms. So here I've just written the list um of what you need to look out for mention at least three of these. Um And on the next slide, I'll go into all of these in a bit more detail. So starting off. So essentially the patients in your cardio exam will be normal for year three. But this is a useful slide for conditions just to be aware of what the signs look like. So for clubbing, you can see the ends of the nails appear wider and a bit spongelike. Um and then you can sort of learn and have an idea of the conditions that clubbing relates to cardiac conditions that relates to later. But things like infective endocarditis or congestive heart failure and then splinter hemorrhages. So they're small areas of bleeding under the nail which can appear like splinters. And this is quite key in infective endocarditis. So it's a good thing to look out for Osler's nose. And Janeway lesions look quite similar, but they can be differentiated by asking if they're painful or not. So, yeah, Osler's nodes are painful and then gary lesions are painless, then peripheral cyanosis. So you can see a bluish tinge in the ends of the fingers due to there being less perfusion there. Then you have tendons on the matter. So you can see cholesterol deposits in tendons and they look quite sort of yellowish and smooth. Then you have cap refill. So you'd ask the or you'd squeeze the end of the patient's finger for them and it should turn pale and then the time for the color to return over the time for the color to return is your cap refill. And if it's over two seconds, then that's a problem. Um And then finally tar staining, it's just something to look out for. It could be a sign as to whether they smoke. So as I said, your patients will be normal in your th year through osk, but this is still important to learn just for your conditions anyway, so you can have a look through that in your own time as well. So, yeah, moving on with hands and arms, you then wanna assess for CO2 retention flap. So how you'd do that is you'd ask the patient to close their eyes, um cock their wrist back and then stay like that for 30 seconds and you'd observe for any flap, then radial pulse. So you'd measure that 15 seconds times it by four, your patient will be normal. So as long as you give any pulse that's divisible by four in your presentation, you're good. And then after radial pulse measure the respirate for another 15 seconds while pretending to feel their pulse. Um just so you cover their respirate and then after and then remember both these numbers as well later on as you will need to present them and then assess radio radial delay. So you can feel for the pulse in both wrists at the same time and then see if they are in sync or if they're not. And then you'd offer radiofemoral delay and then for collapsing pulse, the way you'd assess this is you'd ask the patient if their shoulder is sore at all, you'd um hold their right wrist with your right hand, feeling the pulse support their elbow with your left hand and then quickly just lift the arm above the head. Um And that's essentially how you would assess for collapsing pulse. And then you would offer BP, you don't actually do it, but just offer it lying and standing and on both arms. So yeah, this is just um an extra slide. You can look over in your own time for extra detail, but it's just about what all those signs mean. Probably more useful again for conditions than your ay, but I've just put it in there for reference, if you guys wanna have a look in your own time. So moving on to the face. So you've done your general inspection, you've done your hands and arms and now you're sort of working your way up to the face. So first and foremost, look for jaundice or any yellowing of the face and then you wanna inspect the eyes and the mouth and like I did before, I'll show you some pictures for each one just so you can get an idea of what you're looking for. So with Mela flush, you get this red patchy discoloration in the cheeks and it looks a bit like this. And then for xantho asthma, you get these around like yellowish cholesterol deposits near the eyes, corneal arcus. So again, if someone