Module C/D OSCE Flashcards
Echocardiography.
What is it? (as if explaining to a patient in an OSCE)
1. Purpose of an echo
2. Pro’s of an echo?
3. Types of each? Pro of each.
‘An ultrasound of the heart’. Safe - no radiation. No pain. Not invasive - TTE. TOE needs sedation and some numbing to the back of the throat.
Purpose - Assess cardiac structure and function. Assess need for surgery
Pro’s - Safe, widely available, ease of application
Types - Transthoracic (TTE) and transoesphageal (TOE). TTE less invasive, but TOE gets more detailed images.
Echocardiography.
When reading an echo report, what things should you check?
Categories of LVEF?
- Patient name, DOB, hospital number
- Date of scan
- Type of scan (transthoracic TTE or transoesophageal TOE)
- Imagine quality (if poor - needs TOE)*
- Indication for scan (reason for request)
- Conclusions: Any abnormalities found
- LVEF (left ventricular ejection fraction) normal is 50-70%.
Borderline is 40-49%
Reduced ejection fraction is below 40%.
Echocardiography.
What abnormalities can be found on echo?
- Abnormal heart valves
- Congenital heart disease
- Damage to the heart muscle from a heart attack
- Heart murmurs
- Pericarditis (inflammation) or pericardial effusion (fluid in the sac around the heart)
- Infective endocarditis
- Pulmonary hypertension
- Heart failure
- Blood clot (left atrial appendage, cause of TIA or stroke).
Cardiovascular exam
- Intro spiel (say out loud)
What do I always forget!***
INTRO
- Wash hands & PPE***
- Greet patient in a friendly tone ‘Hello’ and smile
- Introduce self: full name and role
- Confirm patient name and DOB, and preferred name to be addressed. ‘Nice to meet you’
- Explain procedure and gain consent ‘I’ve been asked to do a cardiovascular exam, this will involve having a general examination, and me listening to your chest. Would that be alright? Thankyou’
- Check for pain ‘Before we start are you in any pain?’ great
- Exposure, chaperone ‘ and may I ask you to remove your shirt please? Do you want a chaperone?’ Great we’ll get started.
Cardiovascular Exam
Part 1
- You have done the intro. What are the stages?
- Act it out loud
LOOK
Patient’s SURROUNDINGS
- cardiac monitor/ECG
- Oxygen
- Cigarettes
- GTN spray
GENERAL INSPECTION of patient from end of bed. Looking for
- COMFORTABLE?
-BREATHLESS?
cyanosis, pallor, genetic disorders.
PRECORDIUM
- Scars
- Chest wall deformities
NAILS (*ask patient to put hands out)
- Clubbing (causes - bronchiectasis, infective endocarditis, lung cancer. Shamroth window test - no window = clubbing).
- Splinter haemorrhages
- Check temperature
(TURN OVER) FINGERTIPS
- Capillary refill
- Osler’s nodes (tender nodules on pulps of fingertips)
- Tar staining
- Arachnodactyly
PALM
- Janeway lesions (non-tender, flat, erythematous)
- Xanthomas
PULSE
- Rate and rhythm, slow-rising (aortic stenosis)
- Radioradial delay (aortic dissection)
- Offer to check radio femoral delay (coarctation of aorta)
- Collapsing pulse (tapping sensation at radial pulse - aortic regurgitation) (check for pain in arm/shoulder FIRST)
*Offer to check Blood Pressure
Cardiovascular Exam
Part 2
- You have just finished doing pulse/blood pressure. What are the next stages?
Act it out loud
NECK
- JVP (sinus rhythm = double pulse, just above the clavicle. May not be visible. Ask patient to turn their head to their left.)
- Hepato-jugular reflux (If JVP not visible check HJR. Pressing will increase JVP. Ask patient if they have any pain / mind if you press their tummy).
- CAROTID: auscultate with diaphragm
- CAROTID: feel for volume and character (half way up neck)
Low volume, slow rising = AS
Rapid upstroke and down stroke = AR
FACE
- Malar flush (mitral stenosis)
EYES (‘now could you look up for me and pull your lower eyelids down’)
- Conjunctival pallor
- jaundice
- Corneal arcus
- Xanthelasma
MOUTH (‘now could you open your mouth for me and lift up your tongue’)
- central Cyanosis
- Assessing dental health
- high arched palate
Cardiovascular Exam
Part 3
- You have just finished looking at the face, eyes and mouth. What’s are the next stages?
Act it out loud
INSPECT CHEST
- Scars
- Cardiac devices
- Chest deformities
FEEL
- Palpate apex beat (5th intercostal space, midclavicular line, fingers just under nipple. Start laterally and move medially)
- Heaves (heel of hand)
- Thrills (palpable murmers, 4 areas, with bases of fingers)
CHEST
- Diaphragm (4 areas)
- Bell (4 areas)
- Ask patient to roll to left side: Listen to mitral area (check if radiates to axilla)
- Ask patient to lean forward: listen to aortic area (check if radiates to carotids)
BACK
- Lung bases (on back. Crepitations - LVF)
- Look for sacral oedema
LEGS
- Look for scars and oedema (greater saphenous vein graft - medial aspect of leg. short saphenous vein - lateral leg)
- Press for oedema
- Palpate calves for tenderness (DVT)
FINISH
- Thank patient and tell them they can get dressed
- Present findings to the examiner
Peripheral Vascular Examination
What are the steps of the full examination?
Which parts would you do If told ‘lower limb only’?
Things I often miss!
- Look UNDER HEELS and between toes for ulcers
- Temperature of legs
- Capillary refill on toes
- COMPARE legs
- Movement and sensation
- Buerger’s test
INTRO
- Wash hands / PPE
- intro self and role
- patient name and DOB
- Explain and consent
- Exposure
General exam from end of bed
- oxygen
- positioning eg leg out of bed
- inhalers
- missing limbs / digits*
- scars*
HANDS/ARMS
- Peripheral cyanosis
- Tar staining
- Clubbing
- Temperature
- Capillary refill
- Radial pulse (state rate and rhythm)
- Radio-radial delay (aortic dissection, subclavian artery stenosis)
- Brachial pulse (both arms, state volume and character eg. strong, regular)
- BP (both arms. wide pulse pressure: aortic dissection, aortic regurgitation) >20 mmHg difference between arms = aortic dissection.
NECK (NOT JVP)
- AUSCULTATE Carotid artery: listen for bruits (whooshing sound), both sides. ‘Breathe in, HOLD, and out’. Bilateral= aortic stenosis or atherosclerotic stenosis. Single or bilateral = carotid stenosis.
- PALPATE carotid artery. if no bruits. Assess character (slow-rising, thready) and volume.
FACE
Eyes - xanthalasma, corneal arcus
Mouth - central cyanosis, Marfan’s
ABDOMEN
- Inspect for any visible pulsation
- AAA: feel epigastric region - Palpate the aorta
1. Using both hands perform deep palpation just superior to the umbilicus in the midline.
2. Note the movement of your fingers:
In healthy individuals, your hands should begin to move superiorly with each pulsation of the aorta.
If your hands move outwards, it suggests the presence of an expansile mass (e.g. abdominal aortic aneurysm).
- offer to ascultate aorta (2cm above umbilicius)
- FEMORAL pulse (both sides)
- Radio-femoral delay
LEG
- Inspect and COMPARE limbs: Discolouration (cyanosis, pallor, rubor), scars, missing digits/limb, ulcers (arterial or venous), gangrene (wet or dry), venous guttering (veins collapsed and look like gutters - in normal patient veins should be full when leg horizontal), hair loss, muscle wasting, paralysis: ask to wiggle toes.
LOOK between toes and under heels for ulcers.
- Palpation of PULSES: femoral. Mid-inguinal point, halfway between the anterior superior iliac spine and the pubic symphysis.
Check that the pulse is present and assess the pulse volume.
Assess for radio-femoral delay:
Auscultate over the femoral pulse to screen for bruits (femoral or iliac stenosis)
- KNEE: feel for popliteal pulse or aneurysm with knee slightly bent.
- FOOT: temperature
- FOOT: capillary refill
- FOOT: pulses - posterior tibial, dorsalis pedis. Compare pulse strength between feet.
- Auscultation for bruits (femoral?)
- Buerger’s test
- Sensation (ask examiner ‘would you like me to check for sensation?’ if so - wisp of cotton wool on check for comparison, then legs distal , moving proximally to check level if any problems with distal)
SPECIAL TESTS
- Buerger’s test. Lift leg(s) to 45 degrees, hold for 2 mins, see if goes white.
Gradually lower legs to find ‘Buerger’s angle’ - the angle at which their leg goes white
Sit patient up and Hang legs over bed. Blue then red - reactive hyperaemia. (post hypoxic arteriolar dilation)
FINISH
- Tell patient the examination is finished
- Thank them for their time
- Dispose PPE and gel hands
- Summarise findings
NB ABPI measurement < 0.9 = PVD.
If told ‘lower limb only’ miss out hands, arms, neck and face ie. just do intro, general look, abdomen and legs.
https://geekymedics.com/peripheral-vascular-examination/
Chest pain history
What are the sections and in what order?
Particular things you’d ask?
INTRO
- Gel hands
- Greet, introduce yourself and role
- Ask patient name and DOB
- Explain & gain consent
PC
Open question ‘Could you tell me what happened?’
ICE
(show empathy)
eg. That must have been scary for you
Do you know what it was?
What were your concerns at the time?
HPC / PAIN
‘Now I’d like to gather some more information about the pain itself’
When did the pain start?
Intermittent / continuous?
Improving / getting worse?
S - Site
O - Onset
C - Character
R - did the pain radiate anywhere?
A - associated symptoms (sweating, clammy, N&V indicate MI)
T - Timing
E - Exacerbating and relieving factors (eg. pericarditis / GORD - positional) Worse when you breathe in? Worse on movement? Relieved by GTN spray?
S - Score out of 10, did it change?
SUMMARISE HPC
SIGNPOST - ‘We’ve talked about the pain (summarise), now I’d like to ask you some questions about your medical history if that’s ok?
PMH
- Previous similar episode / chest pain
- Previous heart problems or cardiovascular disease
- Other health conditions (diabetes, HTN, high cholesterol, obesity).
- Any relevant surgical procedures
SUMMARISE PMH
SIGNPOST
‘Now I’d like to ask some questions about yourself and your family history’
FAMILY & SOCIAL HISTORY
- Any family history of heart problems? At what age did they develop? (Relevant if <60yrs cardiac event)
- Occupation
- Lives with?
- Alcohol
- Smoking (risk factor)
- Diet and exercise
- Do you drive?
DRUGS
- what drugs are you prescribed?
- Taking them as prescribed?
- Do you take any over the counter or recreational drugs?
- Allergies?
SAWTEM
‘Are you other wise well?’
Sleep, Appetite, Weight loss/gain, Temperature, Energy, Mood
Mental health
ICE again if needed
How has this affected you? Effects on life - Fear/ work / Homelife.
What are your concerns now?
SUMMARISE the main points of the history back to the patient
- Do you feel I’ve missed anything important? ANYTHING ELSE you’d like to tell me?
- ‘THANKYOU for your time’
Dispose PPE, Gel hands
Palpitations history. What specific things to ask in the History of Presenting Complaint?
What should you say next after gathering this HPC info?*
Things to ask in particular for a palpitations history:
HISTORY OF PRESENTING COMPLAINT
- Onset - when they did they come on? were you doing anything at the time?
- Timing - How long did they last for
- Rate and Rhythm - Was your heart beating fast? Regular or irregular?
- Does anything make them come or go? Become better or worse?
- Any other symptoms with the palpitations? CHEST PAIN? Did you feel dizzy or faint? Any muscle weakness? Problems with your vision or speech? Confusion?
SUMMARISE PRESENTING COMPLAINT* back to patient and ask if there’s anything else they can remember / anything I’ve missed?
SAWTEM
Have you been well lately or have you had any FEVER or WEIGHT LOSS?
Palpitations history - what are the steps?
INTRO
- Gel hands
- Greet, introduce yourself and role
- Ask patient name and DOB
- Explain & gain consent
PC
Open question ‘Could you tell me what happened?’
ICE
(show empathy)
eg. That must have been scary for you
Did you know what it was?
What were your concerns at the time?
‘Now I’d like to gather some more information about the palpitations themselves’
HISTORY OF PRESENTING COMPLAINT
- Onset - when they did they come on? were you doing anything at the time?
- Duration - How long did they last for?
- Continuous or intermittent?
- Rate and Rhythm - Was your heart beating fast? How fast? Could you measure it? Regular or irregular?
- Does anything make them come or go? Become better or worse?
- Frequency? Becoming more or less often?
- Any other symptoms with the palpitations? CHEST PAIN? Did you feel dizzy or faint? Any muscle weakness? Problems with your vision or speech? Confusion?
SUMMARISE PRESENTING COMPLAINT
ICE Do you have any idea what is causing it?
PMH
‘We’ve talked about the pain (summarise), now I’d like to ask you some questions about your medical history if that’s ok?
- Previous similar episode / chest pain
- Previous heart problems or cardiovascular disease
- Other health conditions (diabetes, HTN, high cholesterol, obesity).
- Any relevant surgical procedures
DRUGS
- what drugs are you prescribed?
- Taking them as prescribed?
- Any over the counter / recreational drugs?
- Allergies?
SUMMARISE PMH & DRUGS
SIGNPOST
‘Now I’d like to ask some questions about yourself and your family history’
FAMILY & SOCIAL HISTORY
- Any family history of heart problems? At what age did they develop? (Relevant if <60yrs cardiac event)
- Occupation
- Lives with?
- Alcohol
- Smoking (risk factor)
- Diet and exercise
- Do you DRIVE?
SAWTEM
‘Are you other wise well?’
Sleep, Appetite, Weight loss/gain, Temperature, Energy, Mood
Mental health
ICE again
- How has this affected you? EFFECTS on life. Fear/ work / Homelife.
- What are your CONCERNS now?
SUMMARISE the main points of the history back to the patient
- Do you feel I’ve missed anything important? ANYTHING ELSE you’d like to tell me?
- ‘THANKYOU for your time’
Dispose PPE, Gel hands
Stroke history eg. TIA, arm weakness
What particular things to ask?
HISTORY OF PRESENTING COMPLAINT
- Assess patient’s ability to understand and communicate information
- Onset: Time of onset of symptoms
- Course of symptoms: How long did it last, did it get better/worse/stay same
- Severity eg. if weakness how weak. Could you move it at all?
- Precipitating factors. Were you doing anything at the time?
- DOMINANT HAND?
- Previous episodes like this?
- Persistent weakness or weakness elsewhere in the body
- Did you have any loss of MOVEMENT?
- Did you have any loss of SENSATION? like numbness?
- Was your VISION affected?
- Was your SPEECH affected?
- Loss of BALANCE or problem walking? (Ataxia)
- Loss of CO-ORDINATION?
- Problems SWALLOWING? (Dysphagia)
- Loss of consciousness?
Explore patients Ideas, concerns and expectations
SUMMARISE presenting complaint
PMH
- Palpitations (AF?)
- Any previous strokes/TIAs
- Stroke mimics: Migraine
DRUGS
- Any recent medication changes?
FAMILY HISTORY
- Family history of stroke or TIA?
SOCIAL HISTORY
- Do you drive? (By law you must not drive for at least 1 month after TIA/stroke)
Post-TIA or stroke driving advice
Don’t drive for how long?
Don’t tell DVLA if…
Do tell DVLA if…
You’re not legally allowed to drive for A MONTH after a stroke or transient ischaemic attack (TIA). Some people have to stop driving for longer, or will not be able to drive again.
DONT need to tell DVLA if
- Car or motorbike driver
- One TIA/stroke with no brain surgery or seizures
- Your ability to drive has not been affected
- Or you recover within one month
DO tell DVLA if
- Lorry/bus/taxi driver
- Your ability to drive has been affected
- You had several TIAs.
- You had more than one stroke in three months.
- You had a subarachnoid haemorrhage (a type of brain bleed).
- You had any seizures.
- You had brain surgery.
- Your doctor tells you not to drive.
- If your disability or health gets worse.
- If one calendar month after a stroke or TIA, your stroke has affected your driving.
- If you need to drive a vehicle with adapted controls.
If you have a licence to drive a large goods vehicle (LGV) or passenger carrying vehicle (PCV), you must tell the DVLA/DVA about your stroke or TIA straight away.
General TIA/driving advice:
'’Although a TIA should not have a long-term impact on your daily activities, you must stop driving immediately.
If your doctor is happy that you have made a good recovery and there are no lasting effects after 1 month, you can start driving again.
You do not need to inform the Driver and Vehicle Licensing Agency (DVLA), but you should contact your car insurance company.’’
Post MI driving advice
How long do you have to stop driving for after
MI, Successful angioplasty
MI, Unsuccessful angioplasty
MI, no angioplasty
MI, Bus/lorry driver
Do you need to tell DVLA as a
- Car / motorcycle driver?
- Bus/lorry driver?
Car drivers should stop driving for:
1 week if you had angioplasty, it was successful and you don’t need any more surgery
4 weeks if you had angioplasty after a heart attack but it wasn’t successful
4 weeks if you had a heart attack but didn’t have angioplasty
Check with your doctor to find out when it’s safe for you to start driving again.
Car or motorcycle licence
You don’t need to tell DVLA if you’ve had a heart attack (myocardial infarction) or a heart, cardiac or coronary angioplasty.
Bus, coach or lorry licence
You must tell DVLA (or get £1000 fine) and stop driving for 6 weeks if you’ve had a heart attack (myocardial infarction) or a heart, cardiac or coronary angioplasty. See GP before returning to driving.
https://www.gov.uk/heart-attacks-and-driving
Stroke history (eg. TIA, arm weakness etc~) - the examiner’s questions at the end
- What further clinical examinations or assessments would you like to perform?
- What further investigations would you order?
- Differential diagnosis
- Management for TIA?
- Driving advice?
- Neurological exam, cardiovascular exam
- Bloods: FBC, U&E, LFT, TFT, HBA1C, serum glucose, lipids
12 lead ECG
Brain imaging: CT/MRI
Carotid doppler - TIA, AF, Hemiplegic migraine
- Aspirin 300mg
Referral to TIA clinic - Do not drive for 1 month. Do not drive until reviewed in TIA clinic.
Palpitations history - the examiner’s questions at the end
- Further clinical examinations or assessments?
- Further investigations?
- Differential diagnosis
- Management for palpitations? if AF?
- Full cardiovascular examination. If AF - CHADSVASC score to assess need for anticoagulation.
- 12 lead ECG, 24 hour holter monitor, Echocardiogram
- AF, atrial flutter, supra ventricular tachycardia, ectopic beats, VT
- If AF - Beta blocker, calcium channel blocker (diltiazem, verapamil). Anticoagulant if CHADSVASC score indicates need - DOAC eg. rivaroxaban.
DVT history eg. swollen leg - what things to ask?
Lifestyle advice?
Differentials?
Ask about history of presenting complaint, symptoms, risk factors, family history.
DVT SYMPTOMS (PC)
- Painful?
- Red? Other skin changes.
- Hot?
- Swollen? (Is one leg larger than the other, or both? DVT > 3cm difference)
- PE symptoms: SOB, chest pain when you breathe? Fainting, fast heart rate, fast breathing.
DVT HPC
- When did the (symptoms) start?
- Unilateral / bilateral
DVT RISK FACTORS
- Recent travel (eg. car or aeroplane)
- Recent trauma
- Recent surgery or bedrest
- On COCP
- Bleeding/clotting disorders
- Overweight
- Smoking
- Cancer ‘have you been diagnosed with any malignancies/cancer?’
- Varicose veins
- IV drug use
FAMILY HISTORY
- Family history of blood clots / DVT? Clotting disorders?
LIFESTYLE ADVICE
- Stop smoking
- Lose weight
- Move your legs: Increase activity / reduce sedentary activities - get up and walk regularly, increase exercise.
DIFFERENTIALS
- DVT
- Cellulitis (screen for fever)
- Venous skin changes eg. hemosiderin
Info giving - what to ask patient
What to remember to do
- How much they know already about the condition/medication (get them to talk first)
- What they want to know ‘what would you like to know? / What would be helpful for you to know?’
- Invite patient to ask questions and ‘stop me at any point if I say something you don’t understand’
- Their concerns (ask few times)
- Chunk and check information (frisbee, not shotput!) set out chunks in the beginning in agenda setting
Eg. First I’ll talk about your condition, then about why this medicine helps’
Repetition and summary
Signposting
Stop regularly to check for understanding and to check for questions
Patient restatement - get them to explain back to you what they know
Chest pain differentials?
Costochondritis (pain on breathing in, pain when pressing near sternum)
Stable angina, Unstable Angina, Prinzmetal angina (spasm)
STEMI, NSTEMI / Acute Coronary Syndrome
Acute Pericarditis (pain is better leaning forward)
Pulmonary Embolism (pain on breathing in)
Spontaneous Pneumothorax
Aortic dissection
What is the driving advice for AAA?
The DVLA says:
- Car and motorcycle drivers must tell the DVLA if their AAA measures more than 6cm and stop driving if it reaches 6.5cm
- Bus, coach and lorry drivers must tell the DVLA if they have an AAA of any size and stop driving if it reaches 5.5cm
You can usually drive again once your AAA has been treated, allowing a month or so to recover from surgery.
Tell patient: Ask GP or check gov.uk website.
DOAC Counselling
A patient asks:
- What is a DOAC?
- Why do I need it?
- How do I take it?
- How is it different to warfarin?
https://www.cambridgeshireandpeterboroughccg.nhs.uk/easysiteweb/getresource.axd?assetid=20601&type=0&servicetype=1
What are the steps to ABPI OSCE station? - performing the procedure
INTRO
- Gel hands
- Greet, introduce yourself and role
- Ask patient name and DOB
- Explain & gain consent
PREPARATION
- Check patient is comfortable
- Gather equipment: Manual sphygmomanometer and BP cuff (correct size), doppler, ultrasound gel, paper towels for cleaning patient, paper and pen for writing results, calculator for calculating result.
ARM BP
- Ask if any pain in arm
- Check cuff size, apply to arm
- Check for brachial pulse physically
- Check for pulse with doppler: apply ultrasound gel. Doppler on, adjust volume, hold like a pen for control, hear pulse.
- Pump up cuff until pulse disappears.
- Release slowly. Note reading where pulse reappears (systolic). Write down result.
- Explain procedure is now finished
- Wipe arm
LEG BP
- Ask if any pain in leg
- Check cuff size, apply to leg (wires pointing up towards patient’s body)
- Check for pulse physically
- Check for pulse with doppler: apply ultrasound gel. Doppler on, adjust volume, hold like a pen for control, hear pulse.
- Pump up cuff until pulse disappears.
- Release slowly. Note reading where pulse reappears (systolic)
- Repeat for DORSALIS PEDIS
- Wipe leg
FINISH
Thank patient
Calculate ABPI : highest foot reading / arm reading
ABPI - what is the formula to calculate ABPI?
What do these results indicate?
> 1.3
0.9-1.3
<0.9
0.6-0.9
0.3-0.6
<0.3
MOSCE: < 0.5
Calculating ABPI: highest foot reading / arm reading
eg.
160 / 120 = 1.33 (Diabetes?)
140 / 120 = 1.16 (normal)
105 / 120 = 0.875 (mild PVD)
70 / 120 = 0.58 (Moderate-severe PVD)
30 / 120 = 0.25 (critical ischaemia)
> 1.3 Diabetics (incompressible calcified vessels)
0.9-1.3 Normal
< 0.9 = peripheral vascular disease
0.6-0.9 Mild PVD
0.3-0.6 Moderate-severe PVD
<0.3 critical ischaemia
<0.5 ‘severe arterial disease’
STROKE EXAM
When grading power in limbs from 0-5, what does each number mean?
(MRC = Medical Research Council)
Describe the anatomical landmarks where you would place ECG chest leads V1-V6
V1 - Right 4th intercostal space
V2 - Left 4th intercostal space
V4 - 5th intercostal space, midclavicular line (under nipple)
V3 - connect a the midpoint between V2 and V4
V5 - Left anterior axillary line at the level of V4
V6 - Left mid-axillary line
Left arm (yellow) - ulnar styloid process
Right arm (red) - ulnar styloid process
Left leg (green) - medial malleolus
Right leg - (black) - medial malleolus
What scars are you looking for in a cardiovascular exam and what could they indicate?
Infraclavicular scar - pacemaker
Mid-line sternotomy scar: located in the midline of the thorax. This surgical approach is used for cardiac valve replacement and coronary artery bypass grafts (CABG).
Anterolateral thoracotomy scar: located between the lateral border of the sternum and the mid-axillary line at the 4th or 5th intercostal space. This surgical approach is used for minimally invasive cardiac valve surgery.
Infraclavicular scar: located in the infraclavicular region (on either side). This surgical approach is used for pacemaker insertion.
Left mid-axillary scar: this surgical approach is used for the insertion of a subcutaneous implantable cardioverter-defibrillator (ICD).
Other smaller scars could be minimally invasive heart valve surgery.
Medial lower legs - Long saphenous vein graft harvesting
