Student Reports on Finals: Cardiology - Ask Doctor Clarke · Student Reports on Finals: Cardiology...

Student Reports on Finals: Cardiology

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Student Reports on Finals: Cardiology Written by students for students Students attending the ADC revision courses are asked each year to give feedback on their experiences in the clinical part of their exams and for comments about the courses. This helps keep the courses up to date and as relevant as possible and also helps to give subsequent cohorts of students a flavour of what’s expected. Please note that any answers suggested by students have not been checked for accuracy. By providing real exam scenarios, our hope is that students will be able to gauge the range of questions which most often appear in clinical exams and that this will help guide them to practise their clinical skills in the areas most relevant both to their exams and to their roles as junior doctors. Students from the following Universities have contributed to these reports: Aberdeen, Birmingham, Bristol, BSMS, Cardiff, Cambridge, Cork, Dundee, Edinburgh, Glasgow, HYMS, Imperial, Keele, Leicester, Limerick, Liverpool, Manchester, Newcastle, Nottingham, NUIG, QMUL, RCSI, SGUL, Sheffield, Southampton, Swansea, Trinity College, UEA, UCL, UCD, Warwick Patient confidentiality: new GMC guidance 2013 New guidance from the GMC was issued in 2013 and recommended extreme caution when using patient related information on the internet. As a result, where patient details have been provided in student reports, these have been carefully anonymised. Furthermore, the cases have been organised by clinical subject area rather than by medical school which provides further anonymisation of data. Health warning: Reports can be misleading Writing down what happened in the exam can be quite cathartic- a particularly useful way of off-loading all the stress- and so may not always give a balanced account, as people tend to emphasise the bits they found tricky. Student report: “Take all the cases that people write about here with a pinch of salt. They seem like nightmares when you read them but in the actual exam you just deal with it and get on with it. I looked at the past questions before my exams and freaked myself out. Just look at these things to get an idea about stuff to include in your revision. I advise AGAINST looking at these things the day before your exam”. Health warning: Remember the standard that’s expected Student report: “In terms of the clinical exams I thought I’d done ok but really didn’t feel I’d done enough to do any more than pass. It turned out that I got As. I think the lesson is don’t get caught up in the Finals circus. They want safe junior doctors who can examine patients and elicit signs, not their next registrar.” Health warning: Trust your own judgement Student report: “My biggest advice is not to listen to students who went before you or to let people freak you out. You always know more than you think you do and will be amazed with what comes out!” If you find these reports helpful, please email your own experiences of the clinical exams: [email protected]



Report The revision course was very helpful. You covered most of the types of questions examiners like to ask. However, really on the day the way you perform is equally or even more important than what you know. If you appear confident and are very articulate you will actually pass, but the problem is most people get too nervous and don’t shine on the day of the exam. My advice is to learn to sound confident and articulate throughout your preparation for your clinical exam. Report: adult CPR Adult CPR - Nothing to note, standard DR ABC approach. Your course was brilliant. A lot of the stuff you covered especially on cardiology and respiratory medicine came up in the written paper. It really provided a good foundation of knowledge which was useful when approaching the writtens. Report: ILS I had to perform ILS on a gentleman who had collapsed with chest pain. . acute care scenario: basically testing ILS - identifying it was VF, shocking correctly then administering the drugs. A little twist - his 'wife' brought in an advance directive - oh no, too late, he is alive again!! Report: ILS Next was our acute care station, a nurse called me to a patient she'd found unresponsive. I did A, B, C and started chest compression and asked her to call 2222 and get help etc. Help took a very, very long time to arrive, to the point i asked her if shed actually done it. Then i had to manage the airway, which i did and made a point of saying ideally this should be two people, especially as i have small hands! Finally the defib was attached, it was VF so i shocked and he started moaning, then they gave me an ecg to read, can't remember what it was, and then i was given an advanced directive to read and comment on its authenticity. he was not for resuscitation, which we'd just done so i commented on that. one point though, did i wash my hands before touching the patient, no i didn't, i definitely got glared at for that, but for gods sake he was already dead! Report: angina Angina. I ran out of time as there was quite a lot to do in the time available. Had to take a history, say that would examine (at which point the examiner would hand over the examination results) and devise a management plan. We had to ask all the pain questions and then ask specific cardiac risk factors (the only one was that the patient was overweight). I also asked about GORD and tried to exclude GORD in my history. Because this took a while, the examiner stopped me to ask what I would do next. I said I would refer her to rapid access in hospital for an ECG/exercise ECG and take bloods for CHO etc. I said I would also offer advice on weight loss and offer a referral to a dietitian to help her. I then said I would also give her a GTN spray in the mean time. The examiner asked me how to use it. The examiner then said if I had one final piece of advice what would it be: I said if the pain doesn't go away with rest/ GTN call 999.



Report: checking blood pressure Firstly thank you for putting on these amazing teaching days! I learnt so much at medicine/surgery for finals that was massively helpful for our OSCE yesterday Blood pressure and ophthalmology. We were given 5 mins to take BP (from the examiner) and then look in the eye for all the letters and write them in the picture given below. Looked in the wrong eye and they'd printed "read the question!" On it which was kind! I attended both the medicine/surgery and obstetrics/Gynaecology and paediatrics courses that you ran this year at BMA house. I found that them to be really useful specifically for the OSCEs. Report aortic stenosis Classic aortic stenosis. I was asked to give the most common cause of this presenting murmur - thank you Dr Clarke! This was a patient with aortic stenosis and AF (I think!). The patient was also morbidly obese. He also had some pitting oedema so I said he could have heart failure. He then just asked me about the management of heart failure and the differences between left and right ventricular failure. Report: CABG Cardiovascular exam (there was a visible heart beat in the chest, still not sure what that was about, and a sternotomy scar along with a medial leg scar. Think the marks were just for guessing that he'd had a CABG) Report: aortic regugitation Think was patient with aortic regurgitation. Full CV examination INCLUDING BP. A few questions at the end: what do you think is diagnosis? How would you investigate? Report: valve replacement Another straight forward station. My patient had a valve replacement and the examiner liked that I picked up on the safety bracelet he was wearing and mentioned it. The patient was also wearing socks and the examiner looked pleased when I asked to remove them and checked the patient's peripheral pulses and looked for pitting oedema and ulcers. We were expected to take BP in this station too - some people struggled and ran out of time so couldn't finish the rest of the exam. I asked if I could leave it to last and the examiner said this was fine. I ended up having time to take it in the end, but it meant I didn't feel too flustered for time during the rest of the station. Report: mitral stenosis Cardiology - my patient had AF, had a sternotomy scar, and mitral stenosis. We were expected to do a cardio exam including blood pressure. The examiner then asked me to present



Report: mitral and aortic valve disease Cardiovascular examination: my patient had both aortic stenosis and mitral regurgitation. I was asked to explain the symptoms the patient was likely to have. Common causes of both types of murmur. I was asked to describe the difference between left and right heart failure and what the patient was more likely to have. Lastly I was asked about investigations and management Report Thanks very much for your course. It was really helpful coming up to exams to help put everything together! A lot of your stuff was great for the OSCEs but it also helped with the written papers. (QUB) Report: chest pain history Chest pain history (NSTEMI): Diagnosis? Differentials? Management? Interpret ECG?

Report: pacemaker CVS examination of a patient with a pacemaker. Asked about indications for pacing. I couldn't really remember so just threw out a few sensible ones, then just as I was about to finish I remembered something about heart block (Mobitz type II and above) so offered that up. Report: pacemaker Cardio exam - patient had AF and a pacemaker. Then asked about the indications of pacemaker. The examiner constantly interrupted me during the examination, for example if I said there is no finger clubbing he wanted to the cardiac causes for the sign. Each sign I reported he quizzed me on... so I was pleased I knew all the one's I said! Report: mitral regurgitation and CABG Cardio- mitral regurg + vein harvesting from both legs and left radial. Questions were on how to assess severity and articulate how severe I thought this patient was and what the treatment was, both medical and surgical.

Report: aortic valve replacement Questions: Present your findings What is your differential diagnosis? I said aortic stenosis/sclerosis, and all the other less likely things. What symptoms would you expect a patient to suffer with AS? What other clinical signs would you look for in aortic stenosis? I said narrow pulse pressure, slow rising pulse, possibly quiet S2 So any other diagnosis? I finally twigged with a tissue aortic valve replacement. And he looked quite pleased. How would you treat this? He looked impressed when I mentioned TAVI and BAV Report I found the course to be excellent...extremely well delivered and massively helpful....for example I have always struggled with remembering the reflexes, but it is there in my memory now thanks to the little dance you showed us.



Report: valve replacement Cardio: So an overweight man was sitting there with a metalic heart valve ticking away and a midline sternotomy scar (good good) get the basics down. I was asked if there was anything else I would like to examine, I said I could look in the eyes for roth spots, but that was not what he was looking for. I summarised a normal well man with a midline scar and a click on S1, loudest in the LSE, I didn’t say mitral valve replacement. I was asked for management, I said return to clinic periodically (didn't say for echo). I was asked what investigations I would do, so I said coag and INR. The bell went. OK possible pass but felt clumsy, 'err' too much but I did the basics and got it right. Did check for shoulder pain, before did collapsing pulse, Only checked for chest pain when palpating apex, couldn't find, but didn't even say that. (This was a pass and a good one, there was some discussion about management of metallic heart valves and warfarinisation which I felt I got right.) Report: acute coronary syndrome Presented with a pt with acute MI. Stuck to ABCDE and took as history as I went. Isolated it as an MI fairly early on, but didn’t pass this station. Did not give a good differential for chest pain even though I know tons of these! Forgot the dose size for aspirin in MI, even though I knew this before. Forgot the E in 'romance' for MI. I didn't explore each of the symptoms properly. I didn't clear up discrepancy between his history and the GP letter. Didn't offer to cannulate, didn't offer to take a temp or measure O2 sat. Didn't check with a senior before thrombolysing: this earned a yellow card. I found acute stations quite hard, I have not really had a good chance to practice thinking on my feet. We had the ILS day, but we follow a protocol without much thought there. Report: systolic murmur Aortic stenosis - everyone seemed to either get AS or MR. I tacked on "but I'd like an echo to confirm" at the end of my findings and they liked that. Report: pansystolic murmur Some sort of pansystolic murmur! Unfortunately, I can't confidently say what it was! It was pansystolic (grade 3) and radiated everywhere (including both carotids and axilla). It appeared to be loudest at the left lower sternal edge.. The discussion centred on clinical signs used to differentiate between the various systolic murmurs.

Report: systolic murmur Cardiac examination; aortic stenosis very loud it even radiates to the axilla (was about to say mitral regurg first but then found that it radiates loudly to the carotids). Asked how do you know it wasn't severe (asymptomatic patient and apex beat was normal in character). Also asked what other health professionals should be informed. DENTIST. Also asked about CHADSVASC and contraindications to warfarin from a GP's point of view. Falls was what they wanted. Had to mention HASBLED score as well but not asked anything further about it.

Report: atrial fibrillation Complicated cardiac exam on a post op ortho patient, with old midline sternotomy. Right leg in bandage made me think it was a CABG for a second, but age of scar didn't add up. There were no other scars on the limbs. Cardiac exam was otherwise normal, until I listened at the apex and heard an irregular rhythm. She was in AF: I had some how missed it at the pulse. In the end I'm not sure what she had the thoracic surgery for, but I think it was simply atrial fibrillation that they wanted us to elicit.



Report: atrial fibrillation Lady with bilateral carotid endarterectomy scars and midline sternotomy scar. Was asked to comment on what surgery she had done, what the risk factors were if they were left, when to operate, what other risk factors there were for stroke- which led to talking about A.Fib and the CHADS2VASC score and alternative options for anticoagulation. Report: systolic murmur Man with a systolic murmur, A.Fib and displaced apex- I heard it loudest at the aortic area but there was no radiation so in hindsight it may have been mitral regurg, but they asked me about the causes of aortic stenosis, the differential, symptoms they would present with and the commonest valve involved in rheumatic heart disease. Report: atrial fibrillation Atrial fibrillation. Causes of irregular irregular rhytm. What are the stigmata of infective endocarditis in the hands. Reasons for a non palpable apex beat. ( DOPE - D-dextrocardia, O - obesity, P - Pericardial effusion, E - Emphysema) Define the apex beat. Report: valve replacement Prosthetic mitral valve replacement in a man with atrial fibrillation. I was then asked what I would be concerned about if he presented with fever and signs of sepsis. After answering infective endocarditis I was asked about how to dx infective endocarditis and what prophylaxis he might need in the future for surgical procedures. Report: aortic stenosis in young patient "Feel this woman’s pulse and listen to her heart" A young woman (30- this threw me I was wondering shit shit shit is this going to be a VSD?) with a murmur radiating to the carotids. Causes of aortic stenosis, how is it different in a young person than an elderly patient. How does aoritc stenosis present, What are the treatment options for her, what are the treatment options for an elderly patient- what if they are unfit for surgery, what does TAVI stand for. Report: valve replacement Last patient had an audible valve, sternotomy, was in a fib and had a displaced apex beat. Had to do a full cardio exam. Was asked about difference between peripheral and central cyanosis (should have just said shunt straight away and saved a lot of time), what I thought the reason for this lady's valve replacement was, acute and long term management, chemical vs electrical cardioversion, drugs used for chemical and their contraindications. Report: mitral regugitation Mitral regurgitation (Full CVS exam). Questions: Would I expect the apex beat to be displaced, complications of heart failure and it's management Report: aortic stenosis Pulse and praecordium on a patient with aortic stenosis Report: unstable angina History taking (5 minutes) - chest pain (unstable angina Report: acute coronary syndrome History, ECG and management of acute MI



Report: acute coronary syndrome Assessment and conversation to a registrar over an acute patient with PMH of angina, HTN and now, in AAU, ECG changes, pulmonary oedema and chest pain with dropping O2 sats, BP drop. Indicative of a NSTEMI How I tackled this scenario was to go in, briefly introduce myself to the ‘registrar’ and begin to do an SBAR-esque discussion. I read the literature provided and told her that the pulse was high, BP was perhaps low for a man with previous HTN and that his ECG was showing abnormalities consistent with a potential NSTEMI– which is why I wanted her opinion. I thought that the chest xray showed signs of pulmonary oedema (perhaps I could have said about cardiomegaly – this could have been acute heart failure). It was a chat about what I thought was wrong with this gentleman. I thought I did ‘OK’, but could have exemplified the SBAR situation a bit more and spoken more about abnormalities found. I thought I did a good enough job of conveying my concern. When asked about immediate management – I immediately stated ABCD and site a venous cannula. Time was then finished. Report Well, Finals went well & I Passed!!!!!. I firmly believe that your courses helped me achieve my dream. I got Satisfactory for the writtens & Distinction in the OSCE & I know for sure that this was down to you. I used your technique on every station when I didn't have a clue as to the answer & each time the examiner took the bate & asked me about what I had just stated - I hardly answered their actual questions at all!!! I am sooooo very glad I came on your courses! I used your workbooks as my main textbooks - annotating them with my own notes etc. They were brilliant. I'm keeping them for mrcp! Report Thank you for an excellent weekend at the course. You've hit the perfect balance between high-yield knowledge for writtens and additional caveats for the OSCE. Report: valve replacement history/ endocarditis Had to take a history first, I think I spent too long on it coz hardly had time for questions after. Pt said he had two valve replacements after getting IE, one of which had to be revised because of stenosis. I could hear the click from the end of the bed. So auscultation didn’t really add much, no flow or regurgitant murmurs. I thought it was both mitral and aortic replacements, but other people thought something else, so not sure.

Presented pt as tachycardic, and he asked me why the pt would be tachy. He asked me what drugs he would be on, I said warfarin, and then realised that he may be anaemic therefore tachy. He asked the causes of anaemia in this pt, I said haemolysis and bleeding secondary to warfarin. Then he said but in THIS pt (he was black) so I said sickle cell disease. Then bell went. Examiner was totally stone faced, didn't smile or even nod at all.

Report: aortic stenosis Slow rising pulse, impalpable apex and silent chest. Absolutely panicked at having to turn to the examiner and tell him I couldn’t hear a thing but would suggest it was AS. He told me to listen again which was pretty useless since no one else on the circuit could hear anything either. He asked me what the signs for MR and AS would be in a textbook. It seemed a pretty unfair patient to bring in, but if I could do the station again I would push for an echo, ECG, CXR and Hx in my presentation.



Report: valve replacement Metallic aortic valve replacement with systolic flow murmur, midline sternotomy scar. Nice examiner and lovely patient. The examiner asked me about the indications for aortic valve replacement and anticoagulation for metallic valves. I did a full cardio exam, and then presented. I only found a midline scar. I didn’t think anything else was wrong. I presented as a CABG and asked to examine for a scar on the leg. And she kept asking "are you sure?". So I was freaked but stuck to my guns because I didn't want to make anything up. Turns out he had a mechanical valve and I missed it. Apparently you could hear it when you were close to him. But I was just asked a few questions about management of hypertension and CABGs. Report: bradyarrhthmia This was a tricky station for me. The elderly man had a fall 4-5 years ago and I had to investigate it. So I asked about before, during, after. What they did in A&E when he arrived. He had pretty much no past medical history, drug history, family history or social history of note. He said at A&E they said he had a Bradycardia (in my head I thought - OH NO! I HATE ARRHYTHMIAS!!!!). He also had a new onset symptom of pins and needles in his hands and feet. Finished taking the history and thanked the patient. The examiner asked me to present. I summaries the history and said my top differential would be secondary to a cardiac cause. She asked me about bradyarrythmias then. I was stuck, and I knew I had set myself up for this. So I worked from first principals and gave a differential saying it could be due to a disruption between the SA node, AV node and bundle branches, like in heart block, electrolyte disturbances. She asked me any other causes, I hesitated. So she asked me what valve would be most affected, I said mitral valve is associated with atrial Fibrillation. To which she said this isn’t AF, what other valve will be affected in an 85 year old man? So I said degeneration of the aortic valve.... the penny dropped. "This patient has aortic stenosis!!!! Syncope, chest pain and breathlessness". She said yes! Then she asked me how I would investigate the patient if he came into my GP surgery after an episode like this. Then she asked 'What do you think of him turning down a pacemaker?' I said I would like to explore his reasons more fully. She said 'What about driving?' I said he would not be able to drive. She then asked 'If you saw him in the parking lot driving his car, what would you do?' Classic SJT. Gave my best answer but overall I'd say this examiner didnt look very happy. Report I would like to thank you for your course. Your handbook covered practically everything in the exams. Your course is very worth while. I passed, 2 marks off honours (little annoying) but very happy and I attribute it to your course work and my hard work. I want to say, what worked for me was going into every station (plus using alcohol gel), being extremely courteous to both examiner and patient, smiling throughout and pretending that I was a Dr. already and I wasn't nervous or scared. I spent my minute prep before each station telling myself to relax, get into the zone, before each station rather than thinking about what I might get asked and panicking.



Report: ejection systolic murmur The patient had an ejection systolic murmur and a huge scar across his chest. It didn’t quite sound like aortic stenosis, but I presented it as my top differential, keeping mitral regurgitation and rare right sided murmurs as differentials. I did an examination, presented it to the examiner and kept talking. I said the relevant negative findings (no Heart Failure, no Infective endocarditis) spoke about the investigations I would do and what I would look for on them (Urine dip - haematuria secondary to IE, ECG - left ventricular hypertrophy and deviation, CXR for pulmonary oedema or calcified aortic valve, echo looking for JESP (Jet velocity, Ejection fraction, Size of valve, Pressure gradient), Infective endocarditis, Cause of aortic stenosis). Treatment depends on severity of aortic stenosis and how fit the patient is for surgery, spoke about TAVI and Open valve replacement. The bell rang. The examiner said 'Very good. Are you revising for finals or MRCP PACES? Do you want to be a medic?' Obviously I said YES! And I saw him tick excellent in every box. In my head I thought (hopefully this makes up for the history station). Turns out he actually had Pulmonary Stenosis, and was a complicated patient transferred from another hospital Report: dextrocardia Patient with a subclavicular scar but on the right side just like a pacemaker scar ... he has dextrocardia and a valve replacement. Examiner asked why would he need a valve replacement in his case? Looking for a congenital cause? Not sure what was the answer.... Report: valve replacement Elderly lady with midline sternotomy scar and metallic valve. No other signs. Was asked which valve it was, said I was unsure from auscultation. (It was aortic) Examiner asked: What are indications for valve replacement? What other treatments do we have for Aortic stenosis? Causes of AS? What investigations would you do? Report: mitral regurgitation Straight forward cardiovascular exam, the patient had a mitral regurg murmur and your heart sounds definitely helped me here. All I remembered was rehearsing how this murmur sounds over and over again. As soon as I heard it, I instantly knew what it was. Questions asked: what murmur is it? what investigations would you order? Report: pacemaker Cardio Ex: There was a GTN spray at the bedside and he has a pacemaker scar with a palpable pacemaker underneath it. I finished this bang on time but was a bit put off by the examiner when he asked me for my differentials. I said arrhythmia or angina but clearly this patient wasn't experiencing chest pain then. Also, I'd want an ECG before diagnosing a weird heart rhythm. Report: prescribing for STEMI Prescribing for STEMI: Easy, hold on the heparin as patient is undergoing angioplasty. Report: valve replacement Cardio examination – had mitral valve replacement. Examiner wanted to know which heart sound I heard the click in, he also told me that the patient had an aortic stenosis as well but I couldn’t hear it.



Report: left ventricular failure Medical History – was acute ventricular failure. Patient had had two previous MI’s, was recently becoming short of breath, and had orthopnoea and PND, also had ankle swelling. No cough, no temperature. Report: prescribing in acute coronary syndrome Prescription - STEMI. I did the ol' MMNAC on the stat side, SAAB C on the regular, nitrate and the morphine 3 on the prn. I didn't think fluids were necessary. Report: mitral regurgitation Woman with mitral regurgitation and was Brady. Summaries and DDx asked what other murmur it could be ie aortic stenosis. Given ECG which showed atrial flutter and asked what other Ix I would do: CXR, Echo, cultures if new murmur. Report: rheumatic heart disease and SBE Elderly woman with a history of rheumatic fever and murmur. i knew my murmurs but totally messed this up due to nerves. She did reveal she had infective endocarditis halfway through the exam, which the examiner hadn't been told. She had a leg ulcer - asked about current problems. she had a sternotomy scar. Report: mitral stenosis I had my exam today and my first patient was having malar flush with warfrin medic-alert necklace and signs of mitral stenosis Report: patient with coronary heart disease A woman in her 70's who had previously had angioplasty for angina but had been well since. She had no symptoms at all so i focused on what she'd had in the past and what interventions etc, it was rather short because she just kept saying she was totally fine. Examination i thought id messed up as another student heard a systolic murmur, which id missed (although usually ok if systolic) and i also missed corneal arcus and xanthelasmata, which are silly things to miss so i was rather annoyed at myself. I was then asked lots of questions about managing chest pain, differentials, basic investigations etc, but for treatment it was very confusing what the consultant wanted as it was unclear if he was talking about angina, unstable angina, or STEMI etc. Report I'm writing to express my thanks for your wonderful courses - I went to all four during my final year (not in 4th year as a lot of people in HYMS do). I'm very glad I did…. Well, wasn't I glad I went to your ObGy and Paediatrics course!! It wasn't anything specific from the days, it was just knowing that I'd covered the material of whatever it could be when I walked in the door and saw the little girl or pregnant lady was very very reassuring and ultimately calmed me down enough to take a history, perform a good examination and respond to direct questioning... I would advise ALL four days of courses for anyone in final year in HYMS and elsewhere. £200 for 4 days of extremely high yield material is worth every penny for these high stakes exams. You can't go far wrong if you work from what's in those books. You'll kick yourself if you don't go and cases like mine came up. Thanks again Bob, I'm now a doctor!! Report Thank you so much for an amazing 2 day revision course in Manchester. I passed my finals!!!!!! So happy, can't even express how thankful I am to you for the most valuable revision tips you provided us with. I attended all available revision courses for finals, but yours was the most useful. It gave me an excellent revision focus, and as a result confidence in my knowledge.



Report: valve replacement and CABG Cardio Exam - instructions saying "please Auscultate this patient's heart", and I remember how you warned us about the No-win instructions, thus was really focused on listening to the heart, but at the end said I would like to examine hands, face, legs, auscultate lungs, etc…. On inspection patient had a big midsternotomy scar, starting almost from the sternal notch and ending at the level of umbilicus. There was no pacemaker, no audible prosthetic valve click, and on auscultation I realized that it was systolic murmur, however hesitated to say which valve was affected. There was also a big long scar from vein harvesting on the left leg (Long saphenous vein). Examiner asked me what will I do in order to find out which valve was affected, I said I would do ECHO. It was not my best station, but I passed it and think that the most important thing was to be able to spot the signs, and from the written feedback I realised that I identified systolic murmur correctly, but still did not say the diagnosis. Brilliant courses (Medicine, Surgery, Obs&Gynae and Paeds)! I passed every station! My advice would be to keep calm, read each station carefully and be professional and confident inside the station. If your not sure about something, don’t guess, say that you don't and that you would ask a senior/look in the bnf ect. Report: acute chest pain Acute station - chest pain. Straightforward station, patient complaining on retrosternal chest pain, which does not radiate anywhere. Had some spicy food on a night before. I took focused history, performed quick cardio exam, said I would like to have a look at ECG, do bloods, Chest X ray. Provided differentials: gastro causes, cardiac causes, resp causes (oesophagitis, gastritis, oesophageal rupture, ACS, pericarditis, atypical presentation of pneumonia). Report: acute chest pain Clinical scenario +ECG + Xray + Blood + ABG (no patient / simulation) 5 mins to interpret all the info and then present to examiner and discuss management plan. Bloods normal, ABG metabolic acidosis, Chest X ray pulmonary oedema, ECG anterior MI (but not classical barn door ST elevation - took me a while to work it out). After I said MI I got qs on the managment. Report: acute chest pain- musculoskeletal Efficient history (closed questions, only including what I needed to know). Airway patent because answering questions. Assess Breathing (ascultate, ask for obs e.g. RR, O2 sats). Assess Circulation (ausculate heart sounds, check pulse, JVP, CRT, ecg). Two wide bore cannulae- one in each antecubital fossa and bloods from them (all bloods + cardiac markers). My patient had musculoskeletal pain based on history and exclusion. Discuss investigations / management. Report: atrial fibrillation Cardio exam plus questions on causes of AF. Ran out of time at this point but I'm sure questions on mx were coming next. Report: AF and mitral regugitation Cardiovascular examination- "please report your positive findings and alter your examination depending on what you find" Standard cardio exam. Pay particular attention to the pulse which I normally overlook as this gentleman had AF. He also had corneal arcus and xanthelasma. Finally on auscultation he had a blowing pan systolic murmur radiating to the axilla. Routine. Was asked for the causes of AF but nothing on mx.



Report: atrial fibrillation A patient with the worse case of AF ever. It didn’t feel irregular at all. As I got to the end of the exam I knew something must be wrong so I re-palpated the pulse whilst I was listening to the heart beat. With a bit of concentration I guess it was irregularly irregular. A lot of people didn’t get it. I knew I’d found the right pathology when he asked me for the causes of AF. I said the standard three and he looked at me as if to say ‘is that it’? So I told him another ten at least. Report: pacemaker and JVP Performed a standard cardiac exam, noticed the patient had a pacemaker, also had a systolic murmur. Thought I wasted time by repositioning the patient to examine JVP but on my feedback it said good positioning for JVP exam. Asked what I would do to investigate I said echo for the murmur and an ECG which would show pacemaker spikes, examiner looked pleased with this. Report: acute chest pain Ahh the acutes. I felt like we'd had hardly any teaching on this and what we had had was conflicting (I.e. whether to do ABCDE). My advice would be not to bother with that but mention it at the start after your intro, I said something like 'ordinarily I would use an ABCDE approach but as X is able to chat with me, I'll proceed with history and examination, however I would like to see an obs chart'. Then I would take pretty much a full history, just really quickly. And during your HPC rule out other differentials. I was marked down for just asking if the patient drank alcohol and not getting him to specify how much. So my understanding is that they want a detailed relevant history, fast. Revise your examinations and make mini acute chest pain exams, often I was hurried along or they said things like 'skip that bit'. Then you'll get asked to present and give differentials and management. My guy had musculoskeletal chest pain but you'd wanna rule out resp causes. Report First of all, thank you for your help as I felt a lot more confident with my exams after I attended the course. Also, your exam tips came in extremely handy. In particular, I felt that just standing back to inspect the patient before I proceed with the examination was very useful for almost all the stations, and it helped me gather my thoughts, consider all the clues, and proceed with a plan. Also, components of the course which looked at conditions such as neurofibromatosis and acromegaly were extremely helpful as they appeared in the exams for some of the days, and these are conditions we don't normally see in day-to-day clinics but they expect us to have knowledge about. In summary, there were NO surprises. Seems like you can achieve a safe pass in each station for having a systematic and comprehensive approach, but to score well needed to show a good knowledge. A few examiners specifically noted on whether I looked confident; seemed to be important. Report: valve replacement Cardio: metallic heart valve replacement, i was asked what medication is he likely to be on and chatted about warfarin for a bit. Report: valve replacement Patient had an audible click from the end of the bed, midline sternotomy and aortic valve replacement. Also had a lot of bruising- asked what medication is she on and why?



Report First of all thank you very much for your course, it was great..I really found it helpful to refocus on the important topics for final year. I also found the specialties such as renal and rheum and ortho very good to have been introduced to in the first semester even though we do the specialties in semester 2. Report: aortic stenosis. Questions include symptoms of AS, treatment of AS and types of prosthetic valves. Report: valve replacement Aortic metallic valve. Praecordial scar was barely visible and very faded, patient had a lot of chest hair, so I would say to look very closely at the chest on inspection to make sure you don't miss any scars as this was the key clue to the case. I know it sounds very simple and would be obvious but in this case it was easily missable. I said I heard a loud s2 on auscultation. Listed causes of aortic stenosis, and specific what was most likely in this patient as he was younger 50's, so unlikely senile calcific, more likely bicuspid aortic valve. Was asked what I could ask patient to support metallic valve, I asked about anti coagulation, he was on warfarin, asked what was ideal inr for aortic metallic valve. Asked what I knew about new oral anticoagulants, and were they licensed for metallic valve, I said no, only for a fib prophylaxis and dvt prophylaxis in orthopaedics. Report: pacemaker, coronary heart disease and heart failure I got a patient who came in with shortness of breath. He had a background history of asthma, ischaemic heart disease, stents, heart failure. He also had a pacemaker. I was examined by an anaesthetist and a renal consultant. I was asked to perform a respiratory exam, the indications of a pacemaker, the complications of a pacemaker, the difference between a pacemaker and an ICD, how you would tell if the heart rate was paced or not clinically, how the pacemaker affects surgery, the indications and side effects of beta agonists and ACE inhibitors, the indications and duration for dual antiplatelet therapy Report: aortic stenosis Aortic stenosis murmur. Just asked to listen to the heart. Then asked the indications for aortic valve repair, the different ways of doing it, the differences between a tissue and metallic valve in terms of patient selection, long term follow up and anticoagulation Report: atrial fibrillation and aortic valve replacement Told to examine the cardiovascular system. On inspection patient had a midline sternotomy. I started at the hands, didn't find much. Pulse was irregularly irregular - would consider atrial fibrillation and multifocal atrial tachycardia - need to distinguish the 2. I thought the patient had a collapsing pulse - lifted his arm. Checked face, carotid pulse. Palpated the apex beat, a bit displaced - told the examiners. On auscultation there was a loud second heart sound. I said this patient had a prosthetic heart valve - most likely aortic. Report: aortic stenosis Aortic stenosis. Nearly a full cardiovascular exam so very little time for discussion. They asked how i was measuring JVP and where to look for it. They asked how to find where to listen to the aortic area(weird but other people got this too). Then asked how I'd know if it was severe.



Report Thank you for all your help on the revision courses. I found them extremely useful, they particularly helped to pinpoint areas I was confident with and areas which I was struggling with, or had even neglected completely. I passed finals with merit, and I am sure that your course and revision books were partly to thank for this. Report: valve replacement and pre-op assessment A full cardiovascular examination with pre-op assessment. Don't think there were many marks for the pre-op bit because my friend missed this out and still got 9.6/10 on this station! I was ushered past mallampati stuff so assume it wasn't that critical My patient had a mechanical valve replacement as well as a pan systolic murmur. He was wearing a medic alert bracelet for warfarin. Report: perform an ECG Applying chest leads of ecg on a dummy torso and interpreting 3 ecgs (af, vt, mi) and treatments for them. First, I had to place ECG stickers in the correct location on a mannequin, explaining to the examiner the anatomical location. Then I was handed 3 ECG tracings and asked to identify them. AF, inferior STEMI and VT. Also asked how we would manage each of these conditions. Pretty straight forward, was not even asked to connect the leads to the stickers. They did change the ECG tracings on the fourth day though, so don't be caught out by thinking they will stay the same just because they have done Monday-Wednesday. Report: murmur and pre-op assessment Fourth station was cardio with pre-op review. Another confusing patient as when I asked for BP, I was given a hugely obvious wide pulse pressure of something like 140/40, however on auscultation I heard an obvious ejection systolic murmur in the aortic region. Some people on my circuit found the same but just offered aortic regurgitation. However, I said I could hear a murmur consistent with aortic stenosis, but the wide pulse pressure made me think of aortic regurgitation. I then completely forgot to perform any kind of pre-op examination, and just had to tell the examiner what I would have done at the end - neck flexion and extension, can they lie flat, look in the mouth, dentures etc. Again, this station showed that you really don't need to give perfect diagnoses etc, as I scored very well on it, much to my surprise. Report Thanks again for your course and videos. They really helped me prepare for exams. Report Let me begin by thanking you ever so much for the revision course and the wealth of knowledge you shared at the course. You have some part to play in getting me closer to being a doctor, which I am proud to say I am today. Report: atrial fibrillation A pt with AF. Had to do cardiovascular exam, interpret ECG then use CHA2DS2 VASc to see if appropriate for anticoagulation. Report: valve replacement Cardio - aortic stenosis with questions about midline sternotomy and complications of valve replacement



Report: aortic stenosis Cardiac station - asked to palpate and auscultate the praecordium. Patient had a very obvious Aortic Stenosis murmur so I was delighted! The question afterwards was to name all the systolic murmurs I knew of Report: valve replacement Examine this patient's praecordium: there was a metalic valve + MR Qs on that : What are the complications of valve replacement ? Report: valve replacement Aortic valve replacement. Sternotomy scar with aortic stenosis. Questions on complications of valve replacement and I rattled off your post course valve replacement complications and the examiner ended the exam with 1 minute Other types of valves (biological) and why would you use them. Report: beta blocker for heart failure Cardio: explain carvedilol to a patient with heart failure. He was not keen to take further medications. We had to explain using the percentage of patients who benefit in a year from taking the medication. You are given time to read some information about carvedilol which says that the death rate at 1 year following diagnosis of heart failure is 20% for those not taking carvedilol and 13% for those who do take carvedilol. You have to talk to the patient and explore their situation and their concerns about starting another drug, and then explain the rationale (including the numbers) for starting carvedilol. I think you should also explain the risks and side-effects as you would for any other drug. Report: ECG recording and interpretation. You are asked to take an ECG recording from a patient. This involves putting all the electrodes on the patient and also telling the examiner the surface landmarks you are using for each electrode. You then have to attach the wires to the electrodes correctly. For me this took a very long time because the wires had an unusual design and were very tangled to begin with. You then explain how you would take the ECG recording. The examiner then shows you an ECG trace which shows sinus bradycardia and you are asked to interpret it (using a systematic approach). Report: chest pain Patient had previous angina and had an anterolateral STEMI, history was focussed on the chest pain and associated symptoms/risk factors of MI. Report: mitral regurgitation Cardiac exam - either MR/AS (unsure which, was quite difficult to hear!) Q what would you see on this patient's echo? Report: acute coronary syndrome Chest pain history (Myocardial Infarction) - Q. interpret the ECG Anterolateral ST Elevation. Then how would you manage the patient within 30 minutes (PCI + medical management) Report: mitral regurgitation Cardiovascular examination specifically looking for a heart murmur – our brief said to do a full cardiovascular exam focussing especially on signs for a murmur. My guy had mitral regurgitation. We were asked what the likely causes were. Singing the different murmurs and heart sounds (in my head) helped me figure it out so thanks!



Report: perform an ECG ECG lead positioning and interpretation – we had to place the chest leads onto a manikin in the right place, talk about where we’d place the limb leads, and then describe an ECG. I don’t think I got the diagnosis of the ECG right (some thought atrial fibrillation, others thought heart block) but it was emphasised in the brief that the points were for making sure we systematically talked through the ECG. Report: aortic sclerosis vs stenosis Cardiac exam- murmur: scenario said not to examine abdomen or lung bases. It was aortic stenosis/sclerosis with a mechanical heart valve (probably mitral). Examiner asked for my diagnosis and what the difference between aortic sclerosis/stenosis is. He looked thrilled when I could answer... A lot of the other students missed the mechanical heart valve because the scenario said diagnose the murmur. Report: aortic stenosis My shorts were first, aortic stenosis with atrial fibrillation. I spent a really long time trying to feel her right radial pulse and could only feel her left pulse, but then stupidly listened to her chest while feeling the nonexistent pulse in her right hand. Then later reported that her pulse was impalpable on the right, and they gave me a hard time about why I was palpating her right wrist instead of her left on auscultation...but turns out her right pulse was actually impalpable, and others had lied and had said that they felt it, so just be honest! Report: long case ventricular fibrillation Long case was a patient post MI with heart failure going for a CABG. Since it was so straight forward, got asked intensely about pulseless vfib. Didnt know what to do after trial of one antiarrhyhmic, shock 200, 200, 360 and CPR-- really pushed me for the answer but didn’t know. They wanted adrenaline. Otherwise went well. Thanks again Doctor Clarke...I honestly think every medical student should use your resources. I doubt I could have gone into these exams this confidently without your help. Report: long case unstable angina and JVP Long case was unstable angina... I killed it! Great patient, great examiners and great questions. I was asked about risk factors the patient had. Examine the chest and prove my findings. Even asked me about the wave forms of JVP. It was just perfect. Report: valve replacement A young boy with a ticking metallic valve I could hear as I took his pulse. I knew it was something congenital. I went with aortic valve replacement. Found it difficult to get age specific with my differential so I had to say them all and say it was unlikely to occur in his age group. Before I left the bed side I was asked would he need antibiotic prophylaxis for infective endocarditis going for a dental procedure. I named the most common bug and said it was subject to debate but the guidelines state no Report Thank you for the brilliant courses, they were a massive help in the run-up to finals and really enjoyable. I found the different presentation techniques really useful as I can struggle with traditional lectures at times but the interactive nature of your courses was a breath of fresh air. I also thought the course booklets were excellent in terms of content and layout.



Report: atrial fibrillation For my medical case I had lone atrial fibrillation with the paitient awaiting pulmonary vein isolation. They asked me the management of acute presentation of AF (cardioversion etc) then about anti coagulation. We also talked about the impact of alcohol and I was asked to do an assessment of his alcohol intake. Report: aortic stenosis Obese man, do cardiovascular examination. Dr Clarke- this one I don't know if I fluked it or if this is allowed... Started off on hands, Thankfully didn't say what i was looking for because when i went to feel pulse could feel nothing (I'm bad at pulses when i'm nervous, but this was horrendous- I could feel nothing!) So luckily I didn't have to comment cos I hadn't commented on the hands, tried to assess collapsing pulse (just to go through the motions and sneakily see if i could feel the brachial- nothing) moved on to face. Nothing to see. Felt the carotid. Thank God! It was there,. felt just enough to decide it was regular and that i would run with a rate of 68bpm, JVP, could see nothing, went to feel for apex and thrills etc- well you didn't think I would feel anything there. Then went to auscultate. Started at mitral area... nothing, nothing with bell, diaphragm, breath out, axilla, tricuspid, sit forward, breath in breath out, pulmonary area. I was begining to wonder how bad it would be to present every thing back and say I could feel and hear nothing.... and then THANK GOD in the aortic area was Aortic stenosis. I could have hugged the patient. Check carotids, There it was again. Listened to lung bases and checked legs. and turned and hit them with my spiel (man increased body habitus, no peripheral stigmata, pulses rate regular character and volume of carotids, no JVP, on ausc ejection systolic at the aortic, rad to carotids, grade 3/6, harsh in nature, exacerbated by exhalation consistent with aortic stenosis.) They asked how would i know severity- i said clinically, the pulse was actually challenging to feel (!!) and that could be consistent with low volume pulse, also symptoms and based on echo gradient of >50mmHg or area <0.75cm2. That was it. We moved on. My examiner actually complimented me on my solid clinical skills the day of the results and referenced listening to hearts Report: aortic stenosis Aortic stenosis:..was asked about the symptoms and management(when you decide to do valve replacement and all). I answered when patient is symptomatic and/ or pressure gradient more than 50 etc. They were happy about it and the last question was about TAVI. Report: pacaemaker Second case was a patient with a palpable device in the chest (pacemaker) and auscultate the heart(mitral valve repair). Why is it mitral valve? Indications for mitral valve repair. Mitral stenosis causes and presentation. What to look for in mitral stenosis examination (malar flushing). Report The revision courses were really useful and really well presented. There were many, somewhat fundamental, principles of medicine that I had convinced myself I understood that actually until I was in your lecture I don't think I really had - so thank you! Report: valve replacement Cardiovascular exam for a lady with A.Fib and mitral valve replacement , causes , complications , treatment ( warfarin ) absolutely know everything about anti-coagulants .



Report: atrial fibrillation and pulse deficit My second short was 'examine the heart' - made sure to clarify what the examiners wanted, and they just wanted me to auscultate the praecordium. The patient had atrial fibrillation with a pulse deficit, they asked me about this and I gave your line about 'loss of diastolic filling time with a fast ventricular rate' and they were happy with that. I also thought I heard a quiet murmur throughout the praecordium and presented it as a grade 2 AS murmur (in hindsight, given that he had AF I probably should have guessed a mitral murmur?) but they nodded so I think it may have been a lucky guess. Then the gastroenterologist who was examining me asked if I thought the patient was pale...I thought he was...examiner asked why this might be, and the only thing I could think of was Heyde's syndrome...cringed as I said it 'cause it just seemed like a very unlikely answer...but he actually looked impressed, so I think that may have actually been the answer he was looking for? Report: ALS ALS- standard defib station, but then they threw in some post-resus care and management of bradycardia which I wasn't prepared for. Then the next part of the station (5 mins) you had to review the fluid chart and hang up a drip for the correct bag of fluids. He had been prescribed saline with potassium, and so you had to choose the correct bag, hang it and connect it to the cannula. A few people were unsure actually how to do this. Then he asked me some questions about basic fluids calculations (e.g. what is the rate of 1L over 4 hours, how much potassium per hour is that). It is surprising how basic maths skills go out the window in the heat of the exam! Report: aortic sclerosis The lady had an ejection systolic murmur. I said it was aortic stenosis but it hadn't radiated to the carotids and the pulse was normal. After speaking to other students I realised I should've said it was aortic sclerosis. Report: heart failure/ mitral regurgitation. Ideal case, elderly man with some mild SOB on hills, probably secondary to mild HF though he had diabetes so it was possible painless angina attacks. He didn't really have any symptoms so I was able to run through all my cardio/resp symptoms and do a bit of psycho-social. He had a massive murmur, I'm not the greatest at picking them up but even I could hear it! Questions were on causes of MR, Ix for HF, Ix for angina, a bit about endocarditis... I just had to explain secondary prevention to the patient. Report: mitral regurgitation I was asked about what the typical clinical findings of mitral regurgitation are and another cause of a systolic murmur. Asked to describe the differences in MR and AS murmurs and from the history why this was not AS. I had to give the causes of MR and from the history what lead me to think this was a cardiac cause rather than respiratory (aside from the fact the patient had told me his diagnosis!!). All in all really reasonable questions. My communication task was to explain how his pulmonary oedema was going to be managed and then explain warfarin therapy. Report: aortic regurgitation Woman with SOB, cardiovascular system exam. She had a collapsing pulse, bad dentition with very discoloured looking tongue and an early diastolic murmur loudest at LLSE, question: what murmur is your money on? AR. Moved straight onto next station.



Report: aortic regurgitation Very pleasant patient and two really friendly examiners so that made life easier. I also quite like cardio so felt pretty good during this case. Main presenting symptom was palpitations. Took a history of those and explored other cardio symptoms - he had absolutely none. On examination, the patient had the best aortic regurgitation murmur I have ever heard - perfect early diastolic 'lub-taaar'! Nothing else to find on examination. In the questioning - got asked the causes of AR, AS, MR and MS; Characteristics of an AR murmur; investigations and management. Had to explain to the patient about a TOE - even though he doesn't need one and has never had one! I finished a couple of minutes early and they had clearly run out of questions so also quizzed me on the mechanism of action and side effects of statins and ACE inhibitors which wasn't too taxing. Really enjoyed this case so ended day one on a high. Report: aortic stenosis Examiner: Please take this history from this man who presented to the cardiology clinic The man was in his 70s and had been referred from neurology who had picked up an abnormality in one of his heart results. I was almost positive it was Atrial Fibrillation but asked around other heart problems anyway. Examination: I got hung up on the fact that he had no radial pulse! He had very obvious peripheral cyanosis so really it probably was just weak but because I had AF in my head, I was determined to prove it. This meant I didn't even get to the chest to examine by the time the bell went. Apparently I wasn't the only one who couldn't find the pulse either, so other people used the central pulse in the carotid instead (again what i should have done). QUESTIONS I had prepared investigations and management for AF so was very surprised when the examiner told me that if I had got to the chest, I would have heard a murmur. Apart from management and Investigations for AS, I was asked: What is the most likely arrythmia? (AF) How does Aortic stenosis murmur presents? (I remembered ejection systolic) What is the change in diastole? (I had no idea. I just said I wasn't familiar with that) Did I know any other systolic murmurs? (I said Mitral regurg and some conginital abnormalities) Which Congenital abnormalities? (I had forgotten. Think I mumbled something about VSD and then said I couldn't think of any at the time) What are the causes of Aortic Stenosis? (Thanks Dr Clarke! - Calcified valve, congenital bi-cuspid valve, Rheumatic fever - I think i even mumbled something about infective endocarditis but that it was uncommon) What was most likely here? (Calcified valve) What is the difference between Aortic stenosis and Aortic Sclerosis? (I almost smiled at this - Thanks again Dr Clarke!) EXPLANATION 'Explain to the patient the use of an ambulatory ECG' I couldn't remember all the details and the different kinds at the time but just explained why he would need one. The patient asked me if it could be seen under his shirt. I didn't know so I said I wasn't sure but that there were probably loads of different types. I offered a leaflet and that I could get more information for him if he required.



Report: heart failure "This man has been having problems with breathlessness and has recently had an operation, can you take a history please..." I almost had to stop myself doing a little dance inside, this is pretty much the case everyone hopes for. He had heart failure due to valvular disease (repair of which was the recent surgery), and AF. He had rather obvious AF on examination but nothing else to find, and he told me he wasn't on warfarin, which confused me. Though it later became evident he had been told to keep quiet about Warfarin, as I think I was supposed to figure that out. Questions were: - Causes of heart failure - Classification of heart failure - Management of this patient - Interpretation of and ECG (AF) and CXR (pulmonary oedema) - Management of an acute bleed with a patient on warfarin - How would I know whether to give Warfarin? - What makes up the CHAD VAS2 Score - Had to explain warfarin to the patient. Report:: JVP station Very straight forward, described and said the usual things about jvp, did hepatojugular reflux test, also they wanted me to auscultate the lungs, patient had crackles. said I would look for ankle swelling. Report: dextrocardia I had dextrocardia!!! could not find apex beat so tried to hear and very very soft heart sound. so tried on the other side and got it Report: aortic valve replacement Long Case: Lady that had had an aortic valve replacement. Asked to present her full history and exam findings and sumamrise. Was asked to demonstrate measuring JVP and a few questions on waveforms, to take her blood pressure using a manual cuff, and how I would do it if I didn't have a stethoscope. Asked to demonstrate the dynamic manoeuvres when listening to heart. Asked for indications for an aortic valve replacement. Asked about aortic valve murmurs and what investigations she may have had. Asked about her ongoing care and her medications. Also asked generally about patients presenting with chest pain and how I would classify them. I think I did okay, I was very nervous as it was my first clinical case that wasn't an OSCE and that had a real patient and not an actor. The examiner were very nice and encouraging and told me I was doing fine when I got flustered presenting the history and exam to them. Report: Falls due to SVT Patient with a history of falls. Instructions were to take a ‘brief’ history, interpret ECG and blood results (normal ranges given), look at patients drugs, suggest changes to the drugs you should make and inform the patient of this. Patient was in SVT but points went for talking through your interpretation of the ECG – e.g. saying tachycardia got a nod from the examiner. Patient was hypokalaemic and was on bendroflumethiazide, so I recommended that this should be altered – I wasn’t pushed to say whether it should stop completely or just be reduced. The patient was also on too high a dose of levothyroxine, indicated by severe TSH suppression – this may have contributed to his arrhythmia.



He also asked me what simple things I could do to reduce his future risk of falls– initially I struggled to think and suggested hydration (for the second time during this OSCE) and he loved it as much as the first person. He was also looking for things like ensure good lighting, watch for loose cables, clutter etc. What cases will you be examined on? Do let us know after your exams so that we can add to these reports: [email protected]

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Student Reports on Finals: Cardiology - Ask Doctor Clarke · Student Reports on Finals: Cardiology...

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