CLINICAL SKILLS PROGRAM

FACULTY OF MEDICINE
UNIVERSITAS PADJADJARAN

Handbook and Syllabus

CARDIOVASCULAR SYSTEM
2006 - 2007
 SKILL'S LAB SCHEDULE
CARDIOVASCULAR SYSTEM 2006-2007

Date Time Topic Group Instructor Topic Group Instructor

2-Apr-07 13.00-15.30 C D
4-Apr-07 12.30-15.00 History Taking & A B
6-Apr-07 13.00-15.30 Physical Exam of E History Taking of The F
9-Apr-07 13.00-15.30 Pediatric Cardiac D Heart C
11-Apr-07 12.30-15.00 Patient B A
13-Apr-07 13.00-15.30 F E
16-Apr-07 13.00-15.30 C D
18-Apr-07 12.30-15.00 A B
20-Apr-07 13.00-15.30 Physical Exam of The E F
ECG Normal
23-Apr-07 13.00-15.30 Heart D C
25-Apr-07 12.30-15.00 B A
27-Apr-07 13.00-15.30 F E
30-Apr-07 13.00-15.30 C D
2-May-07 12.30-15.00 A B
4-May-07 13.00-15.30 E F
ECG Abnormal ECG Abnormal
7-May-07 13.00-15.30 D C
9-May-07 12.30-15.00 B A
11-May-07 13.00-15.30 F E
14-May-07 13.00-15.30 C D
16-May-07 12.30-15.00 A B
18-May-07 13.00-15.30 Physical Exam of The E F
Pediatric Emergency
5/21/2007 13.00-15.30 Ateries and Veins D C
23-May-07 12.30-15.00 B A
25-May-07 13.00-15.30 F E
28-May-07 13.00-15.30 C D
30-May-07 12.30-15.00 A B
1-Jun-07 13.00-15.30 E F
SKILL LABORATORY MODUL
BLOCK; CARDIOVASCULAR SYSTEM

Topic:
Physical diagnosis of pediatric cardiac patients

General objectives:
After completion of skill laboratory practice the students shall be proficient to perform physical
diagnosis steps in case of heart disease in pediatric patient in order to eligibly acknowledge as
professional health care.

Specific objectives
By the end of skill laboratory practice, the students shall acquire the followings skills in a proficient
level:
 The skill in performing steps in history taking
 The skill in performing steps in physical examination

Syllabus 1:
Sub module 1.1. History taking
Sub module objectives:
After completion of the sub module, the students will able to proficiently to perform
physical diagnosis steps in case of heart disease in pediatric patient in order to eligibly
acknowledge as professional health care

Expected competencies
 Students should be able to perform history taking
 Students should be able to perform physical examination

Topics
 History taking
 Physical examination

Methods
 Reading assignment
 Case presentation
 Discussion

Laboratory facilities
 Class room
 Reading amterial
 Trainer
 Audiovisual
 Student learning guide
 Tutor/ trainer guide

Venue
 Training room

Organizer
 Department of Pediatrics, Medical School Padjadjaran University Hasan Sadikin Hospital

Evaluation
 Writen examination
 Case examination
 Competency assessment in model
 Competency assessment in patient
LEARNING GUIDE FOR HISTORY TAKING OF PEDIATRIC CARDIAC PATIENTS

No STEPS/TASK 1 2 3 4 5
A History taking
1 Greet client/parents respectfully & with kindness
2 Take a gestational and natal history considering:
 Infections
 Medication
 Alcohol
 Smoking
 Maternal condition
 Birth Weight
3 Take a postnatal history addressing
 Weight gain,development and feeding pattern
 Cyanosis, “cyanotic spells” and squatting
 Tachypnea, dyspnea and puffy eyelids
 Frequency of respiratory infections
 Exercise intolerance
 Chest pain
 Palpitation
 Joint symptoms
 Neurologic symptoms
 Medication
B Physical examination
1 Tell client/perents what is going to be done and encourage him/her to ask
questions
2 Help client onto examination table
3 Wash hands thoroughly with soap and water and dry with clean dry cloth or
air dry
Inspection
 General appearance and nutritional state
 Chromossome syndromes
 Color (Cyanotic, pale, jaundice)
 Clubbing
Inspection of the chest
 Precordial bulge
Palpation
 Peripheral pulse
 Respiratory rate, dyspnea and retraction
 Sweat on the fore head
 Blood pressure measurement
 Palpation of the chest
o Apical impulse
o Point of maximal impulse
o Hyperactive precordium
No STEPS/TASK 1 2 3 4 5
o Thrills
Auscultation
 Heart rate and regularity
 Heart sound
 First heart sound
 Second heart sound
o Spiltting of the S2
 Normal splitting of the S2
 Abnormal splitting of the S2
 Widely splitt and fixed
 Narrowly split S2
 Single S2
 Paradoxically split S2
o Intensity of S2
o Third heart sound
o Fourth heart sound or atrial sound
o Gallop rhytm
o Systolic and diastolic sounds
 Extracardiac sound
o Pericardial friction rub
 Heart murmur
o Intensity
o Clasification of heart murmurs
 Systolic murmur
 Diastolic murmur
 Contionus murmur
 Systolic murmur
o Type
o Ejection
o Regurgitant
o Location
o Transmission
o Quality
o Differential diagnosis at various locations
 Diastolic murmurs
o Types
o Early Diastolic murmur
o Mid diastolic
o Late diastolic
 Continous murmur
 Innocent murmur
 Clasic vibratory murmur
 Pulmonary ejection murmur
 Venous hum
 Carotid bruit
ROLE PLAY FOR HISTORY TAKING AND PHYSICAL EXAMINATION
(DOCTOR)

A patient comes to your private practice with circumoral and finger tip cyanosis
Please gather the information from the patient to conclude the history and physical examination
Chief complaint :

Circumoral and finger tip cyanosis

It began since she was one year old
It is getting worse specially after she crying

A. HISTORY TAKING
1. Initial greetings
Good morning, Mrs A, please seat down
Well, Mrs A, can I help you ?
2. Identification:
 What is her name ?
 How old is she ?
3. Chief complaint: circumoral and finger tip cyanosis
 When did it began ?
 Is there suddenly or gradually ?
 Is there spontaneously or after some spesific event ?
 What make it worse or better ?
4. Take a gestational and natal history considering ?
 Have you ever had infections during your pregnant?
 Have you ever had exposure to drugs, radiation or chemical during your pregnant?
 Do you drink alcohol? How heavy ? How many bottle do you drink every day?
 Are you a diabetic?
 How many kilogram was your baby birth weight ?
5. Take a postnatal history addressing
 Does she has difficulty to increase her body weight
 How about does her development and feeding pattern ?
 Does she has dyspneu or short of breath and puffy eyelids ?
 Does she has frequency of respiratory infection ?
 Does she get tired easily when she exercises ?
 Does she has chest pain ?
 Does she has palpitations ?
 Does she feel painful or hurt when she moves ?
 Does she has neurologic symptoms ?
  Does she takes any medicines at the moments ?

6. Take a family history

 Is there any similar diseases in the family, such as Marfan’s syndrome, Noodan’s
syndrome, etc ?
 Do you have a congenital heart disease in your family ?
 Do you have a rheumatic heart disease in your family ?
 Do you have family with history of hypertension and atherosclerosis?

B. PHYSICAL EXAMINATION
1. Tell client/parents what is going to be done and encourage him/her to ask questions.
2. Help client into examination table
3. Wash hand thoroughly with soap and water and dry with clean dry cltoh or air dry
4. Inspection:
 General appearance and nutritional state: the physician should note whether the child
is distress, happy or cranky, well nourished or undernourished or obesity.
 Is there any chromosome syndromes such as Down syndrome, Turner’s syndrome,
klinefelter syndrome ?
 The physician should note whether the child is cyanotic, pale or jaundice
 Is there any clubbing ?
 Is there any precordial bulging in the chest ?
5. Palpation
 How is the peripheral pulse ?
 How is the respiratory rate ? Is there any dyspneu or retraction ?
 How is palpation of the chest; apical impulse, point of maximal impulse, hiperactive
precordium, thrills ?
 Is there any sweat on fore head ?
 How much is the blood pressure ?
 How is palpation of the chest; Apical impulse, point of maximal impulse,
hyperactive precordium, thrills ?
6. Auscultation
 How is the heart rate and regularity ?
 How is the heart sound ? Is there any gallop rhytm ?
 How is systolic and diastolic sounds ?
 Is there any extracardiac sound ? pericardiac friction rub
 How is the first heart sound ? normal or abnormal
 How is the second heart sound ? normal splitting of the S2, abnormal splitting of
the S 2
 How is heart murmur ? intensity, timing, location, transmission, and quality
 What is classification of heart murmurs ? systolic, diastolic, continuous or
innocent murmurs
 If there is systolic murmur: type, location, transmission, quality and differential
diagnosis at various locations
 If there is diastolic murmur: type, location, transmission, quality and differential
diagnosis at various locations
 If there is Continuous murmur: locations, transmission, quality and differential
diagnosis at various locations
 If there is innocent murmur: location, transmission, quality and differential
diagnosis at various locations
 PADJADJARAN UNIVERSITY
MEDICAL SCHOOL

CLINICAL SKILLS PROGRAM

CARDIOVASCULAR SYSTEM

SYLLABUS AND LEARNING GUIDE

 Skill Laboratory Module

BLOCK : Cardiovascular system

TOPIC : Cardiac physical examination in adult

I. GENERAL OBJECTIVE
After completing skill practice, the student will be able to perform history taking and cardiac
physical examination .

II. SPECIFIC OBJECTIVE

At the end of skill practice, the student will be able to understand the procedure of cardiac physical
examination systematically including:
- History taking
- Systematic physical examination of the heart by performing inspection,
palpation, percussion and auscultation

III. SYLLABUS DESCRIPTION

3.1 Sub Model Objective

After finishing skill practice of clinical examination, the student will be able
to perform history taking and cardiac physical examination.

3.2 Expect competencies

a. Student will be able to demonstrate the procedure of history taking
b. Student will be able to demonstrate the procedure of physical
examination of:
- The jugular venous pressure
- The carotid upstroke, presence and absence of bruits
- The point of maximal impulse and any heave,lifts or thrills
- The first and second heart sound
- The presence or absence of extra heart sound, S3, S4
- The presence or absence of any cardiac murmur.

3.3. Method
a. Presentation
b. Demonstration
c. Coaching
d. Self practice

3.4 Laboratory facilities

a. Skills laboratory
b. Trainers
c. Patient
d. Student learning guide
e. Trainer’s guide
f. References

3.5 Venue
Skills laboratory

3.6. Evaluation
 IV. LEARNING GUIDE FOR
PHYSICAL EXAMINATION OF ADULT CARDIAC PATIENT

Procedure for clinical examination

No Steps/ Task 1 2 3 4 5

A. CLIENT ASSESSMENT
1. Greet client respectfully and with kindness
2. The patient should be given adequate explanation about
history taking and the goal or expected result of history taking
3. Identifying patient’s data ( described elsewhere)

B. HISTORY TAKING. Take a medical history considering:

1 Chief complaint
- Dyspnea & Excessive fatigue
- Chest pain
- Syncope/ collapse
- Palpitation
- Edema
2. Present illness (depends on the chief complaint)
- Onset and chronology of chief complaint
- Location
- Quality and intensity
- Factors that precipitate, aggravate or alleviate
- Timing ( onset, duration, frequency)
- Setting in which the symptoms occur
- Any associated manifestation(s)
- History of previous treatment and its responses
(name, dose, frequency of the drug(s)
3. General medical history
- Past history
History of Rheumatic fever
History of COPD
- Family history
- Occupational history
- Nutritional history
4. History of the major risk factors for coronary artery disease
(CAD)
- Cigarette smoking
- Hypertension
- Hypercholesterolemia
- Diabetes mellitus
- Family history of premature CAD

C PHYSICAL EXAMINATION
1 Tell the patient what is going to be done
2 Help the patient to lay down on the examination table
3 Wash hands thoroughly with soap and water and dry with a
clean dry cloth or hand drier
4 The examiner should stand at the patient’s right side
5 General physical examination (described elsewhere)
NECK
6 Jugular Venous pressure
- Make the patient comfortable
- Raise the head slightly on a pillow to relax the
sternomastoid muscles
- Raise the head of the bed or table to 300-450 and turn
 the patient’s head slightly away from the side you are
inspecting
- Identify the internal*/ external jugular vein and the
highest point of pulsation in the right internal*/
external jugular vein point in the lower half of the
neck
*) if the internal vein is impossible to see, the
external can be used
- Extend a long rectangular object or card horizontally
from this point and a centimeter ruler vertically from
the sternal angle
- Measure the vertical distance in centimeter above the
sternal angle where the horizontal object acrosses the
ruler.
- The sternal angle is roughly 5 cm above the right
atrium. Pressure measured is recorded as 5+ …..
cmH2O
- The distance is the JVP
7 The carotid pulse
- Assess amplitude and contour
 The patient lying down with the head of the
bed still elevated (300-450)
 Inspect the neck for carotid pulsation
 Place your left index and middle fingers (or
left thumb) on the right carotid artery on the
lower third of the neck, press posteriorly and
feel the pulsation
 For the left carotid use your right fingers or
thumb.
 Increase pressure until you feel a maximal
pulsation and contour.

 NEVER press both carotid artery at the same

time

- Thrills and bruits

 During palpation, detect the presence or
absence of humming vibration or thrills
 Listen over both carotid arteries with the
DIAPHRAGM of your stethoscope for a bruit
- Put the diaphragm of your
stethoscope on the carotid area
- Ask the patient to hold breathing
ARM
8 The brachial artery
- The patient’s arm should rest with elbow extended, palm
up
- Flex the elbow to a varying degree to get optimal muscle
relaxation
- Cup your hand under the patient’s elbow.
- Use the index and middle finger to feel the pulse
(medial to bisceps tendon)
THORAX
9 Point of maximal impulse (PMI)
INSPECTION
- Supposed to be done in a well illuminate room
- Determine the location of PMI; Normally in Mid
clavicula line, Intercostal space V)
 PALPATION
- Use your fingerpads to palpate the impulse
- Ventricular impulse may heave/lift your finger
- Check for thrill by pressing the ball of your hand
firmly on the chest.

PMI at left ventricular area

 Try to assess the PMI with the supine position
If you fail to assess the PMI try:
Left lateral decubitus position
Ask the patient to exhale fully and stop
breathing for a second
 When examining a woman, displace the left breast
upward or laterally.
 Assess the location:
Normally on the interspaces 4th or 5th

 Assess the diameter

In supine position, it usually less than 2,5cm
and occupies one interspace.
 Assess the amplitude
Usually small and feels brisk and tapping
 Assess the duration
Normally it lasts through the 1st two third of systole
PMI at Right Ventricular area
 Patient should rest supine at 300
 Place the tips of your curved fingers in the
epigastric region.
 Feel the systolic impulse of right ventricular

PERCUSSION
Careful percussion will usually reveal whether
the heart is normal in size or whether it is
definitely markedly enlarged.

One should use the lightest percussion

possible and, with experience, rely more and
more upon the vibratory sense

To determine the left border of the heart,

percussion should begin at the lateral side and
percuss toward the sternum. The dullness
usually reveal along mid clavicular line

To determine the left border of the heart

percuss from left lateral toward medial.
Normally, the left border is in the anterior
axillary line. The right border is in the right
sternal line and the upper border (base of
theheart) in the 2nd left interspace

10 The 1st, 2nd, 3rd, and 4th heart sound

S1
- Listen to entire precordium with the patient supine.
- The 1st heart sound occurs with the onset of the apex
impulse and corresponds to the beginning of ventricular
systole. It has 2 components . one due to mitral valve
closure and the other due to tricuspid closure. Normally
we are unable to distinguish between these component.
First heart sound (S1) is deeper and longer than second
heart sound (S2)
- The carotid pulse is a reliable timing device as it occurs
immediately following the S1

S2
- The S2 has also 2 components. One due to aortic closure
and the other due to pulmonic valve,.Aortic component
precedes the pulmonic component

S3
- S3 is a normal finding in young adult (below 40)
- Is audible after S2 during the phase of diastole
- Put the bell of your stethoscope and press lightly over the apex,
- The sound is a very low frequency sound

S4
- S4 precedes the S1
- It has very low frequency and is heard most clearly at the apex, near xiphoid
or in the suprasternal notch

VALVE AREA
- The mitral valve area is located in 5th left intercostals
space at the midclavicular line.
- The pulmonary valve area is in the 2nd left
intercostals space at the parasternal line.
- The aortic valve area is above the right 2nd rib and
the right 2nd intercostals space at the parasternal line.
- The tricuspid valve area is located in the 3rd 4th left
ICS along the sternal line

11 The presence or absence of any cardiac murmur.

When a heart murmur is heard, identify and describe its:
- Timing
* Decide the murmur (systolic or diastolic)
* Systolic murmur falling between S1 and
S2.

* Diastolic murmur falling between S2 and

S1
* Palpating the carotid pulse as you listen to
the murmur. Murmur that coincide with the
carotid upstroke are systolic
- Location of maximal intensity
Find the location by exploring the area
where you hear the murmur

Describe where you hear it best in terms of

the interspace and its relation to the sternum,
apex, midsternal,midclavicular or axillary line
 - Radiation or transmission from the PMI
Explore the area around a murmur
Describe where you hear it best.
- Intensity
The systolic murmur has 6 grades. Try to
grade murmurs using the 6 point scale as
follow:

Grade 1: Very faint. May not be heard in all

Position
Grade 2: Quiet. Heard immediately after
placing the stethoscope
Grade 3: Moderately loud
Grade 4: Loud, with palpable thrill
Grade 5: Very loud. May be heard when the
stethoscope is partly off the chest
Grade 6: Very loud with thrill. May be heard
with stethoscope entirely off the
chest

The diastolic murmur has only 4 grades.

- Pitch
This is categorized as high, medium or low
- Quality
This is described in terms such as blowing,
rumbling and musical

- Use two important position to listen for mitral

stenosis and aortic regurgitation
1. Ask the patient to roll partly on to the left side
into the left lateral decubitus position
Place the bell of your stethoscope lightly on
the apical impulse.

2. Sit up, lean forward,exhale completely and stop

breathing in expiration

Pressing your stethoscope, listen along the left

sternal border and at the apex.

Major’s. Physical Diagnosis. Delp and Manning 8th Ed. Page 358-455
Batess’. Guide to physical examination and history taking. 8th Ed. Chapter 7
COURSE STUDY GUIDE SKILL LAB

No Topic Sub Learning Me Resource Comp Method Time Reff

Topic objective dia person etency
level
1 Physic Histor Student will Doctor Presentation 60 Barba
al y be skilled to ra
diagno taking take Role play Bates
sis of medical Discussion 60
adult history 30
cardiac
patient
Physic Student will Doctor Practicing 210 Barba
al be skilled Discussion (7 x ra
examin to perform 30’) Bates
ation physical
examination
.
- Inspecti
on
- Palpatio
n
- Percussi
on
- Auscult
ation
EVALUATION SHEET

Steps/ Task 1 2 3 4 5
HISTORY TAKING

1 Greet client respectfully and with kindness

2 Take a medical history. Patient should be given the opportunity
to relate their experiences and complaints in their own way
3 Observed the patient’s attitude, reactions and gesture while
being questioned.
4 The student should direct the discussion and obtain information
concerning the:
- Onset and chronology of chief complaint
- Location
- Quality and intensity
- Factors that precipitating, aggravating or alleviating
- Timing ( onset, duration, frequency)
- Setting in which the symptoms occur
- Any associated manifestation
- History of previous treatment and its responses (name, dose,
frequency of the drug(s)

General medical history

- Past history
- Family history
- Occupational history
- Nutritional history
5 Adult patient should routinely be questioned about the presence
of the major risk factors for CAD
- Cigarette smoking
- Hypertension
- Hypercholesterolemia
- Diabetes mellitus
- Family history of premature CAD
PHYSICAL EXAMNINATION (Bates)
1 Tell the patient what is going to be done
2 Help the patient onto examination table
3 Wash hands thoroughly with soap and water and dry with a
clean dry cloth or air dry
4 General physical examination
- General appearance
- Head and face
- Eyes
- Skin and mucous membranes
- Extremities
- Chest and abdomen
5 Jugular Venous pressure
- Make the patient comfortable
- Raise the head slightly on a pillow to relax the
sternomastoid muscles
- Raise the head of the bed or table to about 300 and turn
the patient’s head slightly away from the side you are
inspecting
- Identify the external jugular vein, find the internal
jugular venous pulsations
 - If necessary, raise or lower the head of the bed until
you can see the oscilation point or meniscus of the
internal jugular venous pulsations in th lower half of
the neck
- Identify the highest point of pulsation in the right
internal jugular vein
- Extend a long rectangular object or card horizontally
from this point and a centimeter ruler vertically from
the sternal angle
- Measure the vertical distance in centimeter above the
sternal angle where the horizontal object acrosses the
ruler.
- The distance is the JVP
6 Sphygmomanometric measurement of arterial pulse
7 Arterial pulse
8 Cardiac examination
- The examiner should stand at the patient’s right side
- The patient should be supine with the upper body
raised by elevating the head of the bed/ table to about
300.
Two other positions are: 1. Turning to left side; 2.
Leaning forward
8.1 Inspection

Inspection should be done in a proper light.

 Respiration (depth, frequency and regularity)
 Dilatation of veins on the anterior chest wall
 Precordial prominence
 Cardiovascular pulsations

8.2 Palpation
 Apical impulse
 Point of maximal impulse
 Hyperactive precordium
 Thrills
 Percussion

- Ausculatation
8.3 Heart sound
 Heart rate and regularity
 First heart sound
 Second heart sound
- Normal split S2
- Abnormal split S2
- Width of split
- Timing of split
- Intensity of A2 and P2
 Extra sound in systole
 Extra sound in diastole (S3, S4, opening snap)
 Systolic and diastolic murmurs
- Timing
Decide the murmur (systolic or diastolic)
(Murmur that coincide with the carotid upstroke are
systolic)
- Shape
The shape or configuration of a murmur is determined by
its intensity over time
- Location of maximal intensity.
 * Find the location by exploring the area where you hear the
murmur.
* Describe where you hear it best in terms of the interspace
and its relation to the sternum, apex,
midsternal,midclavicular or axillary line
- Radiation
* Explore the area around a murmur and determine where else
you can hear it
- Intensity
- Pitch
- Quality
 Extracardiac sound
 Bruit
This is a case about a 54 year old man who admitted to the ER

CHIEF COMPLAINT
Doctor (D): How can I help you?
Patient (P) : I have got a chest pain

ONSET, TIMING
D : When did it start?
P : I felt it 2 hours ago.
D : How long did it last?
P : I don’t know exactly, but it less than 5 minutes.
D : How often did the pain come
P : Actually not so often but in this last two weeks I felt it almost every day

LOCATION
D : Where is it?
P : Over here ( He is clenching on his chest)
D : Does it radiate?
P : Yes. It went to my left shoulder and down my left arm

QUALITY, QUANTITY / INTENSITY

D : Tell me about your pain
P : It was pressing on my chest as if a weight on my chest
D : How bad was it
P : It was so bad that I thought I was going to die.

FACTORS THAT PRECIPITATE, AGGRAVATE or ALLEVIATE

SETTING IN WHICH THE SYMPTOM OCCURS
D : Was it related to your activities?
P : Yes. It was getting worse as I was in a hurry
D : Anything else?
P : Mmmmm, it was also happened when I got mad
D : What then?
P : I tried to calm down and lying on the couch
D : Did it make you better?
P : Yes. I felt much better

ANY ASSOCIATED MANIFESTATIONS

D : Have you noticed anything else that accompanies the pain
P : Well, I felt nausea and it always accompanied by profuse sweating
D : What else?
P : I felt so weak and sometimes vomit

HISTORY OF PREVIOUS TREATMENT AND ITS RESPONSES

(name, dose, frequency of the drug(s)
D : Have you seen the doctor?
P : Yes, I got some medications, but it didn’t help at all

THE PRESENCE OF THE MAJOR RISK FACTORS FOR CAD

D : Do you smoke a cigarette?
P : Yes.
D : How much do you smoke?
P : 10 to 15 sticks per day.
D : Have you ever checked your blood sugar or cholesterol level?
P : No. I never check it before
D : How is your blood pressure
P : The previous doctor said that I have a mild hypertension
D : Has anything like this happened to your family
P : My father was hospitalized due to severe chest pain when he was 44 year old
ROLE PLAY FOR HISTORY TAKING OF CARDIOVASCULAR DISEASE
(Doctor)

A 54-year-old man comes to the Emergency Room with a chief complaint of chest pain. Please
perform a history taking of this patient!
ROLE PLAY FOR HISTORY TAKING OF CARDIOVASCULAR DISEASE
(Patient)

Chief complaint: Chest pain

ONSET, TIMING
 The chest pain was felt 2 hours ago
 The patient doesn’t know exactly how long it lasted, but it less than 5 minutes
 The pain was felt since two months ago and it is getting worse in these last few days.

LOCATION
 The pain was felt on patient’s left chest
 The pain radiated to the patient’s left shoulder and arm

QUALITY, QUANTITY/INTENSITY
 The pain was felt as if a weight on my chest
 The pain was so bad so the patient thought that he was going to die

PRECIPITATE, AGGRAVATE or ALLEVIATE

SETTING IN WHICH THE SYMPTOM OCCURS
 The pain was related to patient’s activity or emotional: it was getting worse as the patient
was in a hurry or get angry
 The pain was alleviated when the patien takes a rest and feel much better

ASSOCIATED MANIFESTATIONS
 The pain was accompanied by nausea and vomit, profuse sweating

HISTORY OF PREVIOUS TREATMENT AND ITS RESPONSES

 The patient had seen the doctor and got some medications, but they didn’t help at all

MAJOR RISK FACTORS FOR CORONARY ARTERY DISEASE

 The patient smokes 10-15 cigarettes per day
 The patient has hypertension since 5 years ago
 The patient doesn’t know his blood sugar and cholesterol level
 His father was hospitalized due to severe chest pain when he was 44 years old
 MODULE OF SKILL LABORATORY PRACTICE

BLOCK: CARDIOVASCULAR SYSTEM

TOPIC: NORMAL ELECTROCARDIOGRAPH READING

I. GENERAL OBJECTIVE
After completing skill practice of normal electrocardiograph (ECG) reading, the students will
able to assess normal ECG correctly

II. SPECIFIC OBJECTIVE

At the end of skill practice, the student will able to measure and analyze the normal ECG record.

III. SYLLABUS DESCRIPTION

1. Expected Competencies
a. Students demonstrate correct normal ECG measurement
b. Students demonstrate correct normal ECG analyses
2. Topic
Normal ECG reading
3. Methods
a. Presentation
b. Self practice
4. Laboratory Facilities
a. Presentation by trainers
b. Students learning guide
c. References
d. Normal ECG samples
5. Venue
Skill laboratory of Medical School of Padjadjaran University, Bandung, at A.5.1.1 Building,
Jatinangor Campus
6. Organizer
Block of Cardiovascular System of Clinical Skill Program, Medical School of Padjadjaran
University, Hasan Sadikin Hospital, Bandung
7. Evaluation
a. Skill demonstration
b. OSCE
 LEARNING GUIDE OF MEASUREMENT AND ANALYSES OF NORMAL ECG

No Procedure Performance Comment

Scale
1 2 3 4
1 Placement of precordial leads
2 Reading of standard calibration
3 Reading of standard paper speed
4 Measurement of heart rate
5 Assessment of regularity
6 Assessment of sinus rhythm
7 Assessment of P-wave
- contour
- morphology
- duration
- amplitude
8 Measurement of PR-interval
9 Assessment of morphology of Q-wave
10 Assessment of morphology of R-wave
11 Assessment of morphology of S-wave
12 Measurement of R/S amplitude in V1 or
V2
13 Measurement of QRS-duration
14 Assessment of amplitude of QRS-
complexes
15 Measurement and assessment of axis of
QRS- complexes
16 Assessment of morphology of ST-segment
17 Assessment of morphology of T-wave
18 Assessment of morphology of U-wave
19 Measurement of QTc-interval

CHECK LIST ECG SKILL LAB

ECG Reading
1. Read the personal data of the patient :
Name, age, gender
2. Read the clinical history of the patient
3. Determine the heart rate :
- Ventricular rate : measure the RR interval ( in mm)
The ventricular rate is : 1500 = …….. BPM
R-R
- Atrial rate : measure the P-P interval (in mm)
The atrial rate is : 1500 = ………. BPM
R-R
- In normal sinus rhythm, the ventricular rate equals the atrial rate.
They can be different in certain arrhythmias and conduction
disturbances
4. Determine the rhythm:
- A .Normal sinus rhythm
- B. Sinus tachycardia/sinus bradicardia
- C. Abnormal atrial rhythms
- D. Abnormal ventricular rhythms
5. Measure the intervals :
- PR interval : - normal range 0.16 – 0.20 sec
- it is shortened if there is an accesory
pathway/preexcitation
- its can be prolonged in conduction disturbances
- QRS interval : - normal range : 0.08-0.10 sec
- it can be prolonged in intraventricular
disturbances (RBBB/LBBB) or aberrant
conduction
- QT interval : - should be corrected for heart rate (QTc : Bazett’s
formula)
- its in prolonged in certain condition (eg. long
QT syndrome, certain antiarrhythmic drugs)
6. Determine the QRS axis and rotation in frontal and horizontal plane :
- normal/left/right axis deviation
- vertical/horizontal/intermediate heart posisition
- clockwise/counterclockwise rotation
7. Analyze the P, QRS, T :
- P wave : - the mean P vector directed inferiorly and slight anteriorly
(normal P wave deflection is positive in I, II & aVF,
negative in aVR)
- the P wave will be abnormal in right/left atrial enlargement
(P pulmonale/P mitrale)
- QRS wave : - it is narrow in normally conducted impulse
depolarizing the ventricle in normal manner.
- abnormal QRS wave form occurred in ventricular
arrhythmias, intraventricular conduction disturbance,
or intraventricular aberrant conduction
- abnormal/pathologic Q wave occurred in myocardial
infarction
- T wave : - normal T wave deflection is directed in concordance
with the dominant deflection of the QRS complex
- abnormal T wave deflection can be found
accompanying intraventricular conduction disturbance,
preexcitation, ventricular arrhythmias.
8. Conclude your ECG reading
Check list for physical diagnosis of arteries and veins

No. TASK 1 2 3 4 5
1 History taking:
Greet client with respect and kindness, and help client to lay
down on the examination table.
 Documentation: date,name, age, home addres,education,working
status.
Past history: injury, allergy, operation, major organ illness.
Family history: same or other illness, diabetes, hypertension,
cerebrovascular accident, cholesterol and triglyceride
abnormality, clotting abnormality.
Personal habit and social custom: tobacco-smoking, alcohol.
2 Physical findings:
Complaints:
Chief complaints: pain, ulceration, varicose-veins.
Complaints and description of severity:
Pain, weakness, cold or hot, skin discoloration, swelling,
ulceration, varicose-veins: telangiectasia, vein diameter.
Location: lower or upper extremity, acral, medial or lateral.
Onset: sudden or gradual (acute or chronic).
Frequency: times per hour/day/week.
Interferes with: sleep/work/exercise/other.
Influencing factors: rest, cold, weather change, menstruation,
emotion, elevation/dependency.
Extremity:
Skin: inspection: discoloration, cold, pallor/rubbor, cyanosis,
hair growth, ulcer.
Palpation: capillary filling.
Edema: pitting or non-pitting.
Musculoskeletal: atrophy or hypertrophy, symmetry, range of
motion, sensory, reflex.
Arterial survey:
Firstly the student should see how the facilitator doing
Palpation (pulse, thrill, aneurysm) and auscultation ( bruit):
carotid, subclavia, axilla, brachial, radial and ulnar (in fossa
cubiti and wrist), digital, abdominal-aorta, common-femoral
(inguinal), superficial-femoral, popliteal (in fossa poplitea),
foot:posterior tibial, dorsalis pedis.

3 Finish. Wash hands with soap.

Reference:

1.Rutherford RB (editor). (2000).Vascular Surgery.5th Edition.Philadelphia:WB Saunders Company.

pp1-8.

MODULE OF SKILL LABORATORY PRACTICE

BLOCK : PEDIATRIC EMERGENCY

TOPIC : CARDIOPULMONARY RESUSCITATION

I. GENERAL OBJECTIVE
After completing skill practice of cardiopulmonary resuscitation, the students will be able to perform
cardiopulmonary resuscitation correctly.

II. SPECIFIC OBJECTIVE

At the end of skill practice, the student will be able to identify the responsiveness and manage
airway, breathing, circulation in critically ill patients during the initial hours when critical care
expertise may not be available.

III. SYLLABUS DESCRIPTION

1. Expected competencies
a. Students perform correct evaluation of patient’s condition.
b. Students perform correct cardiopulmonary resuscitation.

2. Topic
Cardiopulmonary resuscitation.

3. Methods
a. Presentation.
b. Demonstration.
c. Coaching.
d. Self practices.

4. Laboratory facilities
a. Skill laboratory/class room
b. Trainers
c. Audiovisual aids.
d. Anatomy model (infant and child mannequin).
e. Resuscitation equipment
f. Student learning guide.
g. Trainer guide.
h. References.

5. Venue
Skill laboratory of Medical School of Padjadjaran University, Bandung, at A.5 Building, Class
1.1, Jatinangor Campus.

6. Organizer
Block of Pediatric Emergency of Clinical Skill Program, Medical School of Padjadjaran
University, Hasan Sadikin Hospital, Bandung.

7. Evaluation
a. Skill demonstration.
b. OSCE.

IV. LEARNING GUIDE CARDIOPULMONARY RESUSCITATION

No Procedure Performance scale

0 1 2
1. Check for response, whether the victim is conscious or
 not:
 Call the victim with a loud and clear voice.
 Give mechanic stimulation by shaking the victim’s
shoulder.

2. If the victim is not responding, he is unconcious.

 Call for help immediately.

3.  Place the victim on a flat and hard surface in

supine (face-up) position.

4. Open the airway:

 Perform the head tilt and chin lift maneuver to
keep the airway open.
 When cervical trauma is suspected, the jaw thrust
maneuver can be used to open the airway while
maintaining the neck in neutral position.
 Open the victim’s mouth by performing the cross
finger maneuver to check any obstruction.
 Use finger sweep to remove any foreign subjects
found in the victim’s mouth.
 If the foreign subject can’t be seen, remove the
subjects by performing the back blow or chest
thrust (≤1 year); Heimlich maneuver or abdominal
thrust (>1 year) (either one). Each maneuver
should be done 5 times.

5. Breathing
Check whether the victim is breathing or not. Take no
more than 10 seconds.
Put your cheek in front of the victim’s nose and
mouth, and perform the triple maneuver:
 Look for chest wall movement
 Listen to the victim’s expiration
 Feel the exhaled air on your cheek
If the victim is not breathing or periodic gasping/
agonal gasps (infrequent, irregular breaths).
 Give 5 initial rescue breaths to achieve two
effective ventilation.
 Use mouth to mouth, mouth to nose or mouth
to mouth and nose technique (either one).
6. Circulation
Check the circulation by feeling the pulsation of
carotid, femoral, or brachial artery (either one). Take
no more than 10 seconds.
If you can’t feel any pulsation or pulse < 60 beats per
minute and poor perfusion (pallor, cyanosis), start
chest compression. Identify the correct position of
chest compression.

a. Infants ( Less than 1 year of age)

 Draw an imaginary line between the nipples, the
correct position is one finger breadth below the
imaginary line.
 Begin chest compression with two finger
technique or two thumb technique (either one).
b. Child (More than 1 year of age)
 Compress the lower half of the sternum but do not
compress over the xiphoid.
 Put the heel of 1 your hand on the compression
site or the heel of 1 your hand, other hand on top,
on the compression site and begin chest
compression (either one).

The ratio of chest compression and ventilation should

be 30 : 2 (1 rescuer); 15 : 2 (2 rescuers).
The depth of compression should be 1/3 – ½
anteroposterior diameter of thoracic cage.

7 Evaluation
After 2 minutes or after 5 cycles of cardiopulmonary
resuscitation, evaluate the victim’s condition.
 Pulse
 Breath
 Colour
 Consciousness
 Pupil

V. CRITERIA OF PERSONAL PERFORMANCE EVALUATION

Scale Performance Achievement

0 If student doesn’t perform the task
1 If student perform the task incorrectly/incompletely
2 If student perform the task correctly and completely