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Final Year OSCE Series - Abdominal

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Summary

In this comprehensive on-demand teaching session, participants will delve into the important foundations of ABDO, or abdominal exams. Presenter Jasmine will focus on guiding medical professionals from London's Newham Hospital through patient pathology, how to present findings, and ways to suggest investigations. To fully engage attendees, the session incorporates group breakout rooms where real cases will be examined and discussed. Insight will be offered into patient selection for exams based on their likelihood of stability. The session will also dive into detailed explanations and demonstrations of key physical signs medical professionals are more likely to encounter in these examinations. This session will immensely benefit those in need of a refresher or wanting to build upon their current knowledge base.
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Description

Mind The Bleep OSCE Series

The Mind The Bleep OSCE Series consists of 5 sessions covering cardiology, respiratory, gastroenterology, upper & lower limb neurology and cranial nerve examinations. It’s directed towards medical students, especially those with final year OSCEs around the corner!

Each session will cover examinations step-by-step and relevant clinical findings. During each session, there will be cases to practise interpretation of findings and formulation of management plans. We hope this OSCE series provides you more confidence examining patients, improves your interpretation of examination findings and leaves you feeling more prepared for OSCEs.

Session 3

Exam: Gastroenterology

Date: 15/02/24

Time: 7-8pm

Tutor: Jasmine Quraishi (IMT1)

P.S. Following this OSCE Series we hope to cover other OSCE examinations, we will ask for feedback on other OSCE examinations you’d like us to cover for future sessions.

Learning objectives

1. Understand and demonstrate the correct method to conduct an ABDO exam, including the proper steps, precautions and necessary patient preparation. 2. Develop an ability to accurately diagnose the most common pathologies found during an ABDO exam, using knowledge of common signs and symptoms. 3. Gain the skills necessary to successfully present and clearly communicate clinical findings obtained during an ABDO exam to patients and other medical professionals. 4. Learn how to effectively suggest appropriate additional investigations based on the signs and symptoms presented in the ABDO exam. 5. Experience hands-on practice going through patient cases in breakout rooms, aiming to enhance diagnostic, communication, and collaboration skills amongst medical peers.
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Computer generated transcript

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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Ok. Hi, good evening everyone. Um, hopefully you can all hear me well, if not just, um, messaging the chat. My name is Jasmine. I'm in 91 at Newham and in, in London and I'm gonna be guiding you through today, the ABDO exam. So these are kind of a series of ay focused talks. Um, a lot of it will be a, a refresher. You've probably already kind of learned this stuff in previous years, but it's more of a kind of focused, we're gonna focus more on kind of pathology, how to present findings, um, and kind of what your investigations to suggest and then you're going to have some, um, breakout rooms where you go through some cases. Um, so just to give you a little bit of background in terms of, um, my experience osk wise. So I used to be a teaching fellow last year. So I know a little bit about how we select patients for exams. Um, and I'll try and kind of point out which as we go through the presentation, which kind of signs you're more likely to see based on kind of which patients are more likely to be brought to exams. Um, uh, you know, because they're, they're more likely to be stable. So, just to summarize, we'll do a refresher on the ab abdominal exam and the signs that you'll be more likely to encounter, we'll talk through how to present your clinical findings and then you'll have some interact of cases. Um, in the breakout rooms, feel free to put any questions you have in the chat. Um, just in the interest of time, I'll probably look at them when you guys head over to your breakout rooms and then answer those. Um But yeah, anything you want to ask, uh feel free to do that. So um as with any examination, this is all kind of not new to you. Um really, really important basics. So I like this, I've always liked this acronym, the YR acronym, just cos it kind of summarizes the really key aspects that you want to hit as soon as you approach the patient. So you want to obviously wash your hands, you want to introduce yourself and your role, you want to gain permission from the patient. And also as part of gaining that permission, you're explaining what proce what examination you're going to be performing, what it will involve and at the same time, confirm the patient details for exposure. Um You're obviously um going to be thinking about maintaining patient dignity, but really, really important to get a good look at the patient. So you really want to expose them. So ideally waste up and don't be afraid um you know, to do to expose the patient because you may miss signs if you're too hesitant. And I have seen that happen a few times to students in terms of um positioning. So obviously, later, later on in the examination, when we palpate the abdomen, you'll want, you'll want them to be flat, but in the initial stages, it's ok for them to kind of be at 45 degrees. And then in your general inspection, I guess there's two aspects to it. So, you know, this is the the really the key moment where you, you may even pick up the diagnosis just from looking at the patient and the surroundings. So don't kind of neglect this and and and rush into straight away starting your kind of physical examination of the patient. So the patient in front of you, you may from a kind of gi point of view, you're looking to see if they have any obvious jaundice. Um once you've exposed them, you'll be able to see that abdomen. Does it look distended? Can you actually see any visible hernias already? They may have, for example, an incisional hernia or they may have a, a paraumbilical hernia that's, that's visible. Do they have any any scars that you can already see from the end of the bed and any evidence of tattoos? For example, that could be a risk factor for liver disease and then another aspect you can look at is what their nutritional status and c you know, if there are any signs of cachexia, um if in, you know, some conditions that involve malabsorption, that might be an issue for the patient and looking around the bed, um things that often are conveniently placed in Aussies. So Creon, if there's any kind of pancreatic insufficiency, um you may see that other side of the bed, the patient may have drains less likely in a osk setting. But you know, we're, we're also thinking about the abdominal exam generally for your, for your future, you know, your future as doctors, um, any me medication, other medications around the bed, vomit balls, ng tubes and how do they appear? Do they appear visibly kind of grimacing? Are they in pain? Um Are they on any oxygen therapy? And then the other usual things, mobility aids to suggest that they, uh, you know, uh require that to mobilize. So, uh moving on to the kind of first aspect as we approach the patient peripherally. So the hands and the arms with hands. Um I like to start off first looking at the nails and then progressively move on to the palms and then um arms. So with the nails, the things that you're looking for, uh clubbing. So clubbing is a key thing that we look for in many other exams as you know of. So in the cardio exam, resp exam from a gi point of view, we may see that in patients with cirrhosis, um IBD and sometimes also in cac disease, um leuconychia. Er sorry, I don't actually have a picture of it on this slide. Um Essentially you get a bit of whitening of the nail beds and that can be a sign of malnutrition or hyperalbuminemia and chol onychia, which you can see here is spooning of the nails and that could be a sign of quite severe iron deficiency anemia or again, malnutrition. Um moving on to the palms. Um sorry, these were meant to be kind of, these were my original slides. So as they've gone on to PDF, they, they've superimposed. So you can't see them very well, but essentially palmar erythema would be one of the main things you're looking for. So kind of redness of the of the palms and that is is is commonly seen in, in chronic liver disease also in pregnancy. But from a gi point of view, you, the main thing you're thinking about is chronic liver disease. Um Durans, as you can see in this image is essentially thickening of the palmar fascia. So that causes kind of contracture deformities as you can see here of the ring finger. Um And that again, is a is a sign of of chronic liver disease. You can also get it um with other conditions, diabetes. Um And to feel it, it can be quite subtle, it may not be very pronounced. So you really want to kind of um uh palpate it with um you know, oo over the palms. Um I would then move on to feeling the pulse just gives you a sense of how stable the patient is. Are they tachycardic? Um and then move on to, to looking if they have a, a tremor. So patients with alcohol uh withdrawal may have a, a fine tremor and then as you get them to outstretch their hands to look for a tremor, you can then kind of very naturally proceed to look for a um hepatic flap. So asterixis and by that, you essentially get them to um to put their hands out and I basically tell them to put their hands as if they were stopping a bus. So they um put their hands out. And ideally, you want to wait for 30 seconds often if there is, if there's unlikely to be a flap in, in an osk setting, cos that would imply the patient's decompensated. So you may suggest to the examiner that you would ideally wait for for 30 seconds and pro and continue to proceed with your exam from the arms. The main thing you want to be looking for is um are there any presence of a b fistulas in a patient who may have had a previous, um who may have had a transplanted kidney and may have previously required dialysis and had an A V fistula. And if you do find a navy fistula. Uh You want to look to see if there's any Bruits. Um So with your, with your stethoscope listening, uh with the bell and palpate to feel any thrills. And that essentially um gives you an indication of the flow rate. So that's good bl uh blood flow rate if there's any needling in the fistula, that may indicate that the patient is currently undergoing dialysis. So that's quite a useful um observation when you then go present your findings. Um and the other things you can look at on the arms are bruising. So bruising from coagulopathy, for example, again, from chronic liver disease or thinning of the skin. Um and that might just imply that the patients may have been on steroids. So lots of gi conditions that patients will require steroids, for example, IBD, um if they've had any transplantation, any form of autoimmune disease, so that can be quite a subtle sign that you pick up on. Ok. Um So moving on to the neck aspect, so face, um so first of all, just look at the patient from, you know, close up, just observe the face. Is there uh any obvious uh jaundice of the face? Um and then proceed to looking at the eyes more closely at the sclera. Sometimes it can be quite subtle if there is sclera of the jaundice, uh sorry jaundice of the sclera. Um As you can see in this lady, it's, it's pretty obvious but um y you, it can be quite subtle. Um and then conjunctival pallor, I don't actually have an image here. It's something that seems quite obvious. But um it, when we, when we refer to conjunctival pallor, we're actually referring. So the, if you um you might need to Google this after the talk, but essentially when we, the bit of the conjunctiva that's attached to the sclera, um is the, is the anterior rim, sorry, the the the posterior rim and that's usually kind of whitish in color and then the the the anterior rim is red. So that's normal. If the whole of the conjunctiva, the conjunctiva is pale, that implies uh conjunctiva. That is essentially confirms that there is conjunctival pallor suggestive of iron deficiency anemia. So it's a subtle difference um to make sure you don't confuse the two. And we may see that in patients who for whatever reason, have chronic gi blood loss, um or inflammatory bowel disease as well, other signs to look for in the eyes, um corneal arcus, um xantho asthma, and those are signs of hypercholesteremia and then more rarely. But if you do pick up on this, this will pretty much give you the diagnosis. Er Kaiser rings. So these are kind of a dark ring around the iris, kind of copper in color, uh sorry around the iris and, and it implies copper accumulation. So, as we see in, in Wilson's disease, which can lead to uh liver failure. Um So quite a important sign to pick up on if, if it is present. Um some, some mouth signs that are present here. So, um angular colitis, um essentially these kind of cracked sores around the corner of the mouth imply vitamin deficiencies. And you often see it in, in IBD, particularly in Crohn's disease. Um atrophic glossitis, this kind of um uh gross swelling of the tongue in B12 deficiency and just generally oral ulcers from any form of immunosuppression. Um You also see it in, in IBT particularly Crohn's and Candida. Um if the patient is also on, on immunosuppression. Um So those are the kind of the main ones you want to look at so eyes and mouth um for the face um then proceeding to the neck. So I've written here, lymph nodes, you probably don't need to do as thorough lymph node examination as you would do for a respiratory examination. But I would go through kind of the main groups of lymph nodes, submental submandibular auricular um the cervical chains. But the really important one not to miss is the supraclavicular lymph node on the left side. So, varicose node um and that can be a sign of gastric cancer. So you really want to kind of emphasize that you are palpating there. Um The examiner will be looking for that. Um The JVP I've, I've included it here. It's not essential, but it would be very um uh very good to do if you already had some signs that the patient had chronic liver, chronic liver disease. Because essentially by examining the JVP, you're looking to see if there's any um right heart signs of right, right heart failure that might be secondary to their liver disease. So, um you know, relating to liver congestion, so you may, you may want to do that but not essential. And then um acanthosis migrans is this kind of hyperpigmentation that you see it in the skin folds, in the around the neck and also in the axilla area. Um and that can um can be a sign of diabetes and I think some forms of cancer, particularly gastric cancer. Um So if you do, if you do see that um important to pick that up. So moving on to inspection of the chest and abdomen, um by this stage, we would have hopefully already exposed our patient earlier on in the the start of the examination. So you have a, you have a good uh kind of surface area to look on the chest. Um The main thing you're looking for are spider Naevi. So, Spider Nevi, as you can see here are your dilated kind of uh blood vessel capillaries that occur due to high levels of estrogen in patients with chronic liver disease, particularly uh alcoholic cirrhosis, you can get a few Spider Nevi. Um but anything over five is considered abnormal. Um other signs of other other thing other signs that you might get from high estrogen is gynecomastia. Um So that might be quite subtle in some patients or more pronounced in others. Um and also some hair loss. And also to note if they are on spironolactone, which they might be on for their chronic ascites, they may also as a side effect of that have developed gynecomastia. Um looking at the tummy, um obviously, scars is gonna be a, a main part and we'll, we'll talk about that in a, we've got a separate slide to discuss that in a second. You want to look to see if there is obvious abdominal distension. Um Can you see any stretch marks um potentially suggestive of ascites and previous ascites? Um There's, this is quite rare and would obviously be more of an acute finding you'd see in the hospital rather than the osk setting colon sign. And that's this bruising that you get kind of in the subcutaneous fat um around the umbilicus often in the context of um of uh retroperitoneal hemorrhage or er sometimes in acute pancreatitis. Quite rare but important to be aware of. And this was meant to be a video, sorry, you can't see it very well, but it's um a patient with ascites. So you can see the distension of the tummy. Um kit mid, you say so, a sign of portal hypertension, you get these engorged um paraumbilical veins essentially from the portal systemic collaterals forming. Um It's a very sensitive sign for a patient with portal hypertension, um commonly secondary to uh chronic liver disease. So those are the main things you're looking out for, but there may of course be other things like drain um scars from, from drain sites, um er or peritoneal dialysis so very quickly on scars. This is something I won't spend too much time on because you can look up in your own time. Um The main thing that I wanted to highlight is sort of which ones are more like you're more likely to see in an in an exam. So um the Rutherford Morrison very commonly um from kidney transplantation. Remember, patients with kidney transplants are often quite stable provided, they're um obviously, they may be immunosuppressed, but they are often kind of the ideal patients to bring into exams. Um And you may, you may identify the scar from, from uh the surgery that they've had um midline laparotomy. So obviously, this is kind of um incision in the kind of midline following kind of the linear alba. And that kind of would give you quite a wide range of differentials. Um but uh important to identify if you do see it. Um and then Fonte in women, um of course, from previous Cesarean sections, you may need to lower down the kind of um the very, very slightly the underwear just to if it's just at the, at the top of the kind of the suprapubic um area it can be very subtle as well. Um, you may also, it's also important to kind of pick up if you can on kind of laparoscopic incisions because commonly, you know, the, the bulk of the surgery we do nowadays is laparoscopic. So moving, we're moving away from these kind of larger incisions and you may, they may be slightly harder to spot. Um, but do try and, and, and look closely to, to find them um just very quickly on stomas. The reason I have spent a bit longer on this is because this again is a group cohort of patients that can come to OSC exams because they're, they're quite stable in themselves. Um They don't have any active pathology, they've had a previous surgery and they, and, and it's quite a good test to identify students can have been on the wards and seen, seen stomas. So the way to approach this is kind of looking at it from all these different aspects. So, first of all, the site of the stoma, is it in the left eyelet fossa or the right eyelet fossa? So remember more commonly, colostomies will be located in the left ileac fossa versus ileostomies and urostomy more more so in the right ile fossa, how many lumens you can see? And that can, that can give you an indication if it's a loop or an end ileostomy or colostomy. So two lumen, two lumens kind of uh closely located together would be a loop ileostomy or colostomy. Um Is there a spout? Um So that uh would indicate um that it's more likely to be an ileostomy or a urostomy. Um And that's because of, as you probably know, the contents uh are more irritant to the skin. Um So, hence the use of the kind of spout. Um And then, and the, the output is very important to, to comment on as well. So is it solid um or semisolid indicative more of a colostomy? Um liquid bowel content would be suggestive of an ileostomy. And of course, if you can see urine, um it's, it's a urostomy. Um Commonly, these patients can develop complications. Um Some of these are fairly benign. They may have some kind of um uh they may have a small parastomal hernia. So things like that or if there's any, any skin irritation or erythema around, um do comment on that because that will show that you kind of um that you are familiar with examining stomas. Um How are we doing for time? So, 10 minutes left? Ok. So I'll try and power through the next few slides um in terms of abdominal palpation uh and percussion. So, um obviously, the technique, I'm sure you, you guys have practiced this uh on the wards, but um our light palpation will be focused more on looking for signs of peritonism. So make sure you get down to the level of patient and you're observing the face the face very carefully um for any signs of pain. So, if they, if they do tell you they're in pain, if they, if they have identified an area of pain, you always start away from that uh area. Um And then, so guarding and rebound, tenderness, guarding essentially is the, you get contraction of the abdominal muscles in response to pain. So, involuntary, um you'll uh get this kind of rigidity and that will, can often su suggest um peritonism. Um Whereas voluntary, obviously, the p the patient in response to pain will uh tense their abdominal muscles, rebound, tenderness is pain when you remove pressure, um kind of counterintuitively. And that again is a quite sensitive sign for um peritonism um followed following on from your light palpation, you can then follow the same kind of format. Um you know, all the nine quadrants uh assessing for assessing more deeply for masses. Um and obviously warn the patient as you do that, that you're going to press a little bit harder um moving on to kind of more organ specific palpation, percussion and auscultation. So, liver palpation, um the way I like to do this is kind of using the kind of the flat aspect of your index finger. You want to move your hand inwards um at the peak of of inspiration. So often I get the patient to practice breathing in and out just to kind of coordinate the breathing pattern. And you want to start from the right ile ileac fossa, moving upwards to the costal margin. Sometimes you have to go immediately um as well. You can kind of get the, the liver can, isn't necessarily uniform in how it um enlar the enlargement. So, um but I would, I would start in the right, right iliac fossa. Um And even if you haven't necessarily felt a liver edge do percuss the liver because sometimes you can still have liver enlargement, um particularly the patients who have had, for example, thoracic surgery or, or things like that. Um So that's the liver and I like to do palpation, percussion for each organ at the same time. But everyone kind of does things differently. Some people like to do palpate all the organs individually and then percuss separately. So just find a way that works for you. Similarly with the spleen. Um you're going to use the same aspect of kind of flat aspect of your, of your index finger and you're working diagonally this time from the right eyelet fossa towards the left costal margin, you're moving your hand inwards again, matching the kind of the peak of inspiration. Um And your percuss again to identify if there is uh splenomegaly. So you're looking for dull percussion though when you percuss um blotting kidneys. So this is often something that um I remember as a student, I didn't really understand the reality is it's quite unusual to feel a normal kidney unless they're rex um the most common patient that you'll be able to ballot a kidney is in um polycystic kidney disease. So, those are often patients who may come to your exam. Um So you want to make sure your hand is right under the kind of the flank area up to the heel of your hand and you've got the other hand directly um over. So as the patient takes a deep breath, you're essentially flicking um the hand that's underneath the flank area, flicking upwards while your, the hand on the, on the tummy area is pushed down. So you, you may feel the kidney tapping against the hand if, if there is enlargement there. Um And lastly for AAA, um you are um essentially looking to see if there's a pulsatile expansor mass. Um So remember pulsation is normal, so an upward movement. Um but if you can feel it moving outwards, that would imply some form of aneurysm. So that would be your abnormal finding. Um and lastly shifting dullness. So, shifting dullness, um essentially looking to see if there's any presence of ascites. And the way to remember is you percuss away and then you move the patient towards you. So, percuss away from the umbilicus towards the left flank. And then when you um er get a dull re er note to percussion um which can be normal in, in all of us, you know, if there's fluid or feces, you get the patient to roll towards you. And then you want to wait at least 30 seconds to allow enough time if there was fluid to kind of move down the intraabdominal cavity and then you rep percuss. So if, if that percussion note goes from dull to, to resident, then you've got a change that would be positive for shifting dullness. But remember you do want to, to give that at least that 32nd time limit. Um lastly, auscultation. Um So uh looking for renal aortic bruit, renal bruit, either side of the umbilicus just above the umbilicus and for aortic Bruit um in the mid, in the midline. So essentially, um that implies some kind of, of some form of atherosclerotic disease. Um And for bowel sounds, um once you've had bowel sounds in, in one or two places, you don't need to kind of listen in all quadrants as I've seen some, some students doing, but you just want to comment if they're present or absent or abnormal. For example, tingling that you wouldn't expect to hear that in an exam. Uh patient with an active small bowel obstruction. Ok. Um So lastly, the lower limb, so very quickly, um look to see if there's any pedal edema. Um patient, for example, with nephrotic syndrome or actually hyperemia. So, patients with chronic uh malnutrition, they may be on um total total parental nutrition and have had a long period, long hospital stay. They may have a very low albumin level and this may be something that you pick up on and of course, if there is any hepatic congestion from uh heart failure as well. Ok. So that's the kind of very quick whistle stop tour of the exam. Um You want to end your exam kind of the usual stuff. Thanking the patient. I like to offer to assist with dressing. I think it just kind of shows that you care and about the patient. um wash your hands and then just as you're washing your hands, kind of take a deep breath and prepare a few kind of thoughts in your mind about how you're gonna structure your presentation. So I realize we're coming up to half an hour mark. I think I'll be five more minutes. Um team just um because I know you've got your breakout rooms ready. So before we move on to how you would present your findings just very quickly on which investigations you may want to suggest. So always, always start from kind of least invasive to more invasive. Um There are some kind of classic things that are kind of osk uh examinations that you may want to suggest. So, doing apr exam, examining the hernia orifices or examining the genitalia, but try not to just say them without them, without there being some form of relevance to your, you know what in your mind, you think the diagnosis is um suggesting a focused history if that's gonna help you reach your diagnosis, vital signs. So getting a BP, um pulse rate, uh oxygen levels, that's the saturations, that's all um very um point of care stuff that can easily be done. And, and in terms of blood. So think about what investigations you're gonna tailor to what you think the diagnosis is. So if you think a patient um may have signs of chronic liver disease, you may want to suggest that you request an FBC. But don't just say you want to do an FBC, say you want to do an F PC to look for thrombocytopenia, for example, as you might see in chronic liver disease. So just qualify what test the reason why you're requesting uh each test um urine. So obviously, in any women of childbearing age, always suggest a pregnancy test in any kind of acute abdominal pathology. If you think it's relevant um urine MC NS, um stool samples can be, can be useful fecal card protectant is essentially for um can be quite useful for assessing for inflammation, for example, IVD. And then obviously our our imaging um so always start with kind of basic things before moving on to cross sectional imaging. Um So in a rec chest X ray, if you're concerned about perforation or abdominal X ray, um if you think there might be some um fecal loading or there might be signs of obstruction and then moving on to ultrasound and subsequently CT. Ok. Um So very last, very quickly, I just wanted to give you a bit of a structure of how you present your findings. Um because this is something that I personally struggled with when I was a medical student. So I've suggested here two ways of doing it. Um Option A is probably the one that you guys um are more confident in doing. Um because it just allows you to kind of um go through things systematically and, and just give out all the findings um that you have essentially identified without, without having to in advance have thought about what the diagnosis is essentially. Um But option B can be, can appear very slick, can show that you have kind of um you know what you're talking about, you have a real sense of what the presentation and diagnosis is. So option B will look very good to the examiner, but you may not want to do that if you are a little bit unsure about the the the significance of your findings. So uh with option A, you start off by saying the kind of you don't need to say the age or the name cos sometimes as, as you're nervous presenting, you forget those details. But to start off saying I performed an abdominal examination on this lady or gentleman and then from the end of the bed, just state the relevant things that you noted. I noticed that there was some Creon tablets um on the bedside um and the patient had um uh some uh uh a walking stick um also at the bedside um and then the summary of your peri peripheral findings. So you may want, if there's, if they nega if there are no positive findings, you can kind of summarize that as no peripheral stigmata of either gastrointestinal disease or chronic liver disease. Um depending on what uh you think is relevant. But if there are positive findings, then you want to describe these as well as the relevant negatives and by relevant negatives, I mean, things that um the the present, the lack of is also useful in kind of excluding a diagnosis. So the fact that um there are no in a patient with chronic liver disease, there are, there are there was no abdominal distension, suggestive of ascites is a relevant negative finding. Um then you can move on to your kind of each aspect, inspection, palpation, percussion, um auscultation and then suggest three differentials for the findings. Um At that point, you can then suggest what, how you would like to complete your examination and what further investigations you would like to do. You may find that you're kind of prompted by the examiner at that point already. And they kind of ask you, they cut to the chase, what, what test would you like to do but try not to feel put off by that often. It's just the kind of the the time uh the time constraints with option B um you are just kind of focusing on the, the very key findings that you have uh identified. Um And you're essentially using those to justify the how you've reached your diagnosis. Um So this could be used for in a patient who has very kind of obvious signs uh of, for example, like I said, um signs of Wilson's disease. And you really uh you, you want to showcase that you've identified those findings but try and include other differentials. So it shows to the examiner that you have thought, thought about things systematically and you have considered um other differentials other than just kind of being tunneled, tunneled vision on that one thing that you've thought about. Um, cool. So that was a very quick overview of um, the abdominal examination. I'm just going to post a link for feedback and then I think we're going to, um, get you across to some breakout rooms to, uh, to go through some cases and then we'll all get back together after that. Let me know if you have any questions. Thanks, Jasmine. Um Just for everyone else in case you haven't seen it yet, I've just posted in the chat. Um, a list of the, there's only two breakout rooms today, um, but a list of who's in what breakout room. I'm sorry if I missed anyone, I think a few people are sort of, um, leaving and rejoining. But, uh, uh there's only two. So if I've missed you off then just feel free to join a random um at either one of the breakout rooms. That's fine. Um And let us know if any issues, of course. And yeah, thanks Jasmine. Thanks.