I am a cardiology charge nurse recently rotating to a nurse led rapid access chest pain service. This is a new role for me. As part of this role is to clinical assess and examine patients who have been referred by their GP with symptoms possibly of angina. The essay should be written using these guidelines RECORD OF THE KEY FACTS : REFLECTIONS ON THE KEY FACTS: THEORY/PRACTISE LINKS: RESOLUTIONS FOR THE FUTURE This was the first time i had taken responsibility of the clinic by myself although an experenced colleague was supervising/mentoring me. Mr F, a 75 year old gentleman was seen on 15th October at the clinic. At clinic we start by taking a comprehensive history. Using the mnemonic S.o.c.r.a.t.e.s. He had a 4 week history of dyspnoea and central chest pain, non radiating, occuring on minimal exertion with no other associated symptoms. Relieved on rest after 5 minutes. pain starts after dyspnoea. Feels like a dull ache ( he explained like indigestion) Had been on holiday up north 5 weeks ago and had been admitted with dyspnoea. ECG - fast atrial fibrillation - commenced on beta blocker and aspirin and discharged. patient stated his pain was like his hiatus hernia pain he gets. history - hiatus hernia enlarged prostate No allergies normally fit positive family history. clinical examination was then carried out. using systematic approach observation, palpation, auscultation he was asked to have a lie down on the examination bed, the head is tilted to 30 degrees for appropriate cardiac examination. reference I started with mr Fs hands - observing for clinical signs of good perfusion - assessing for colour, warmth movement and sensation. no signs of clubbing or palmar erythema indicating no hypoxia (refeerence) Radial pulse bilaterally was palpated noteing rate, rhythm and amplitude - rate slightly irregular. femoral pulse was palpated. blood pressure was obtained 140/85. Carotid pulse was palpated inividually. JVP measured normal. carotid upstrokes satisfactory. head and facial examination revealed no abnormalities, conjunctiva and sclera nomal with no signs of anaemia, xanthalasma. Mouth clean good dentition. I was unable to locate the thyroid gland (although it takes experience) reference The gentleman was asked to take his shirt off for examination. Observation of his anterior chest showed no scars, rashes, excessive use of accessory muscles. Palpation with my finger tips of the precordium over the aortic, pulmonic, tricuspid and mitral areas revealed no thrills or heaves. I was unable to palpate the apical pulse so i asked mr F to turn on to left lateral to enable the apical pulse to be felt (reference) at the 5th intercostal space and the mid clavicular line. It was felt. i had not felt any thrills or heaves so did not expect to detect any heart murmurs - as some have a contraindication to exercise tolerance test which is one of our diagnostic tools that we use in the clinic. i used the diaphragm of the stethoscope to listen over the areas i had palpated for high pitch sounds then listened with the bell for any low pitched sounds (reference) Low pitched sounds can be difficult to hear. an echo was obtained as being a novice was unsure of a definite diagnosis of no abnormalities of the heart sounds. Carotid arteries were listened to with the bell of stethoscope and no evident bruits heard. No central or peripheral oedema was noted. dorsalis pedis and posterior tibial pulses were felt. Echo was normal. ETT - bruce protocol used, gentleman had symptoms with ST segment depression in his chest leads. It was stopped at 1min 44 secs. for the symptoms glycerol trinitrate sublingual spray was given after this patient had a collapse episode - BP unrecordable, ABCDE -assessed. Airway patent, breathing satisfactory, BP normalising on resting on clinic bed. post ECG carried out which showed persisting St segment depression in chest leads. he continued to look pale cold and clammy. The consultant cardiologist was asked for advice and admission was sort for this gentleman. The gentleman had an angiogram carried out on the 16/10 which showed severe triple vessel disease and he must now be referred for surgery.