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Final Year OSCE Series - Cardiology

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Summary

Join Foundation Doctor Will Manus and IMT2 Dr. Tessa, at Adam Brooks for a highly engaging session in the Mind the Bleeps Osk series. Ideal for final year medical students, this session aims to enrich your knowledge, providing helpful tips and strategies for your OSC exams and beyond, using the cardiovascular examination as our case study. The discussion will guide you through the systematic approach to an examination, focusing not only on the steps but also on time management and understanding the significance of each procedure. After Dr. Tessa provides a detailed walkthrough, participants will be moved into breakout rooms to analyze cases and engage in insightful discussions. So immerse yourself in this essential experience, boost your confidence and ace your examinations. Don't forget to take notes and share thoughts as you go along!
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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 1

Exam: Cardiology

Date: 31/01/24

Time: 7-8pm

Tutor: Dr Tessa Yoo

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 apply a systematic approach in completing a cardiovascular examination. 2. Identify and interpret abnormal findings during a cardiovascular examination and relate these findings to potential cardiovascular pathologies. 3. Gain confidence in executing clinical examination skills through repeated practice and discussion. 4. Effectively manage time within the allowed frame during a clinical examination. 5. Recognize the importance of an introductory process in any clinical examination, including hand hygiene, self-introduction, patient verification, explaining the purpose of the exam, gaining consent, and ensuring adequate patient exposure.
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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.

Yeah. Oh, I could live. Does that mean I've started? Yeah, your life now just. Oh, great. Um Should I start? I can quickly just um introduce it. So, hi, welcome everyone. Um, my name's Will Manus. I'm a foundation two doctor working in the East Anglia Deanery. Um So, yeah, welcome to the Mind the Bleeps Osk series. Uh We have five sessions stretched over five weeks um covering the main clinical examinations. Um, so we hope this series provides you with some, some extra knowledge and some tips for your OSC exams. Um, today we've got, er, Doctor Tessa, you, um, who's an I MT two at Adam Brooks. Um, and she'll be discussing the cardiovascular examination. Um and then after she's discussed the examination, we'll move everyone into breakout rooms to discuss some cases. Um and we've got some tutors to facilitate the case based discussions within the breakout rooms. Um, so you can go through each case and discuss amongst your group. Um, but to kick things off, I'll hand over to Tessa uh to walk you through the, the cardiovascular examination. So, over to you, Tessa. Hi, thanks, Will. Uh thanks everyone for joining this. Evening. I know it's not easy to take some time out during the evening to join the session. But hopefully, um, this sort of hour or so would give you some uh knowledge and, and sort of confidence in um smashing through your ay uh in a couple of months time if you're having your ay examination soon. Um, so just a bit by myself, my name is Tessa. I'm currently Act two and my internal medical training in these Finland, I'm doing my ICU rotation in an Brooks Hospital. Um And I think that's, that's about it really. So I'm just gonna talk through cardio cardiological examination, uh osteo patients. Um So most of you, I from my understanding are final year medical students. Um So a lot of the cardiovascular examination steps you probably would be familiar by now. Um So I'm not gonna sort of focus on that a lot, but rather I prefer to sort of focus on some tips and advice, um how to approach your OS stations and perhaps not only cardiovascular examination but also other examination OSC stations. Um a systematic approach and a couple of strategies and skills that you can use to boost your marks and points. Um And to basically gain confidence in smashing through your stations um based on sort of personal experience and practicing with friends as well. So basically, that's sort of the aim of uh of today sort of talking through uh a cardiovascular examination station um to basically have a systematic approach. Um the steps to everything and that would help you a lot as well rather than having sort of a chaotic uh mind when you approach a station because you're gonna be anxious, you're gonna have lots of things going through your mind. Um So it's important to have a systematic approach. There is a reason for each things that you do in each um step during your examination. Um And there's a purpose of it. So you're not just sort of like doing it for the sake of doing it, you're doing it to try and find any of abnormal findings that would build on the information uh towards your differential diagnosis. Um And you also need to be aware of the abnormal findings on each steps and how they relate to a cardiovascular pathology. Um and also relate those findings towards your differential diagnosis at the end of it. Um And there are sort of a couple of things that you may pick up during your examination that you feel like you want to say, but perhaps may not be sort of, perhaps you, you're not sort of confident enough to say it. Um And I sort of suggest that keep it in your mind and perhaps mention it later towards the end to your examiner. And I think the osteo station is all about being slick in your examination skills and also having the confidence of doing it as well. And behind all of these things that you should also be able to manage your time as well. Um I'm not sure how much time you're allowed for each stations. For me, when I did my few stations, I only hit six minutes in sort of out of eight minutes, I believe. So, I had one minute to read the brief six minutes to do my station, um, and one bit left for any questioning for the examiner. Although I know my juniors now have seven minutes because of the feedback. So it really depends on what your medical school um has designed for you. And from that way, you can sort of manage your time and practice with your friends before you do your examinations. Um So this is just kind of the layout that I tend to keep in my mind when I do any examination, including what I do now to my patients in the hospitals and the wards. Um there is you always start of introducing yourself and getting the patient details, then you proceed to doing your clinical examination. And I always like to break it down into three parts. Basically you look and you feel and then you do or you listen to whatever you need to do. And this applies to any examination of any system, whether it's cardiology or spirit or gi or neuro and everything. After you examine the patient, you then consider any special tests. And fortunately in cardiovascular, there's not many, unlike M SK, we've got lots of, you know, other special tests that you can do. Um So after you've done all your special tests that you can think of, you then take a step back, summarize your findings and you present your findings to your examiner, including your impression and what else you want to do. Um And that's when you mentioned to them to complete my examination, I want it to do this, this this and that. So this is just kind of the, the sort of headings that you should keep in mind when you do any sort of clinical examination osculations. So to start off on the introduction, um I'd say do this as quick as you can and you will develop the confidence in doing this and be slick with it because this basically gives you four brownie points just by doing these simple things. It doesn't even need any sort of medical knowledge to do it. You read your brief, you walk in, know what you're gonna be doing and then just basically do, do these things and you will just get four points easy, four points, wash your hands. And nowadays because of COVID pandemic and any sort of like, you know, respiratory illnesses, um there may be some infection control measures and I presume they, they would mention this in your brief as well, but hopefully not. Um So wash your hands, introduce yourself and who you are. Um get the patient's name, age and date of birth. And this is just sort of clinical governors reasons to make sure that you're actually speaking to the right patient and the age just kind of helps you when you present your summary at the end, um tell your patient what is your purpose of speaking to them or what you're gonna do today. Just so they're aware what to expect. It's very important to get their consent to her and ask if they've got any pain before you start your examination. Um and for cardiovascular examination, it's also important to ensure an adequate patient exposure. So top off and also in a semirecumbent position in the bed. So that are up in 45 degrees if they're not already in that position, usually, I think they're already set up. It's just that you have to get the consent um to remove the top off for good reasons, not for, you know. Um um so after you introduce yourself and do everything that you need, uh get four points from that, you then start your clinical examination. So look, feel and do so you start in the bed end. Um look at the patient, how they look like, how are they anxious, look at the er, breathing, look at the color. Uh are they set up, are they laying flat if they're set up? Are they breathing? Ok, they're laying flat, are they breathing? Ok. Um And just make comments on that if they look well on themselves, then also make a comment to that because if you don't say what you're seeing, the examiner won't know what you're looking for. So I'd say narrate as you go. Um, so if you see, you know, looking at the patient in the other bed, he looks comfortable, not in distress and they set up in a, in a sort of semi common position. Um, or you can say, you know, they look anxious and they look slightly dyspneic and then you look at the surroundings of the patient that can give you clues to what's going on, especially in the war settings. Um, if they've got any oxygen, they've got any ECG leaks. Are they on a cardi monitor? Do they have any equipments around them such as a frame or a walking stick that may indicate that they've got very poor functional status? Um, have they got any sort of lines and that you can see any medications on the bedside that can also give you an indication what's going on in terms of their pathology. Um, then you look for any paper notes, any charts such as infusion, drug charts, fluid balance charts, vitals. Um, although based on my experience, they don't tend to put a lot of things because that can sort of, you know, take a lot of time to interpret those things. Um, but just bear in mind, these are the things that may be around. And if you don't see them. That's absolutely fine. You can always mention it because I'm saying, you know, um I would also keep an eye out for any sort of dropped charts and notes or I would get the nurse to give you to give me the drop charts and notes and stuff like that. So um so at the bed end is pretty quick, the patient surrounding any paper notes, then you start off by looking, approaching the patient a bit more closer and looking at sort of doing your peripheral examination. I like to kind of break down into parts, um body parts and essentially of the cardiovascular examination. So you've got your hands, your forearm, your upper arm and then your neck and then your face and then your chest. So I tend to sort of go up from your hands towards your face and down and for each part, each body part you then do your look feel do um that's just my way of doing it because in that way I can remem II don't miss anything out. Um rather than sort of do it, you know, I would look everything first. I would feel everything first. But if that works for you, that's fine. If you, if you're used to it, that's fine. Just as long as you, you can, you can sort of cover most of the things. And a lot of these sort of pro examination would be what you've already know or learn from your clinical placements and from reading books or looking through, you know, ki medics or whatever resources you use. Um So start with the hands. My um advice would be to try to get the patient to do most things for themselves uh if you want to do things for you. So for example, you want to have a look at their hands, um try not to sort of do it for them Um because they may not like people touching it. You know, if you put yourself in their position, they may, they may not like people touching them as well. It kind of feels like you're forcing them to do things. So just get them to kind of have a look at your hands, uh palm of ceiling and then you can sort of have a, have a look and see if there's any, you know, um propose to marker of any infective endocarditis as you know, any lesions o nodes or any splint hemorrhages, um finger clubbing, any sort of bluish tinge to the nails, any tar staining or any sort of long fingers that may indicate some under congenital disease and stuff. Um Once you had a look, you then feel and always tell the patient what you're doing as you go. So they know what you're doing and also the examiner knows what you're doing. Um So tell them, you know, I'm gonna have a few of your hands now. So a few of the temperature, do your refill a few of the sweaty or clammy. Um And if you find any abnormal findings, just say it out. Um Once you've done with your hands, you proceed sort of more proximately. So filling the limbs, so specifically in the wrist, um looking for any sort of dehydration or very edematous. Um And when I say limbs, it's a mix of upper limbs and lower limbs. And I put brackets too because there's two arm. So always remember to look at two. Um So Graft Harb is in the legs. So what I need and they indicate they may, they, they may have previous sort of cabbage um procedures before any bruising. They may indicate they're on uh blood thinners or on your platelets. And that may also mean that they have an underlying sort of cardiovascular disease that, that, that, that, that uh they need to take these uh medications. So when you have a look, you then feel um for your pulse, comment on the rate and the rhythm, how they feel like what the character is and then you can proceed to doing your radio, radial delay, um feeling for any sort of pitting edema as well on your upper limbs and then do whatever you need to do. Um So assessing for an eps pulse, but always warn the patient, you've got any pain in their arms before you do that because you do need to lift their arm up quite quickly above their head. Um Do a BP as well. At this point, just mention it to your examiner because you won't have time to do it. Sometimes they want you to do it. They may ask you to just talk me through how to do a BP, basically just tell them what to do. Um It's unlikely they would get you to do it because I think that would be maybe a, a separate um station to do that. And if your patient presents with syncope or collapse, then you would also mention that I would also like to do a long standing BP provided safe for the patient to, to, to do that. Um So just mention it to them, I would do a BP in both arms because you may get different readings across both arms. So once you're done, sort of your limbs, see them sort of move upwards towards your face, you can look for any signs of any hypercholesterolemia, any anemia, any signs of, again, you know, um my f probably just sort of indicate they may have some sort of um uh Marfan syndrome or et cetera. Um any bluish to their uh tinge to their lips, um their hydration status, oral hygiene as well, which, which may um sort of point you towards perhaps there's, you know, there's some endocarditis risk over there, not much to feel and do in your face really. Um So once you're happy with the face and then move down towards the neck. You look, um ideally your patient would have been set in 45 degrees. So you get them to look towards the left, I always get them to, to focus on a point that you feel is sort of 45 degrees towards the left of the patient and then look at the neck, um for sort of any sort of race JVP, um which is sort of, you know, you draw a horizontal line from your uh the angle of Lewy of your sternum. Um and any sort of JVP that you can see, which is the tip of the sort of pulsation that is above the clavicle. Then you sort of measure the distance between the angle of the Lewy to the top of the pulsation. Um Anything sort of below three centimeters is normal if you're not sure, just say, you know, I can't appreciate any JP or I can't see any based JVP. And that, and that should be fine. You can also do a reflex at the same time. Um to see if you can accentuate a race J BP. But hold it for at least sort of two cycles of pulsation because sustain more than two seconds means that there probably is a raised ABP. Um Then you feel for the carotid pulse, I'd say mention this, but skip it because in reality, in, in sort of real clinical practice, there is a risk of dislodging, sort of a carotid plaque that may cause a thrombotic stroke. Um, if this patient's got, you know, a AAA sort of acrotic plaque in the, in the carotid arteries and if you're doing it too hard, it may also cause reflex cardiff. So you definitely don't want that to happen during Aussie, er, examination. So just mention it to examiner that, you know, this is how I'd feel for the carotid pulse, er, which you can see on the pictures literally just beside the Adam's tackle. Um um and comment on the character and volume as well. Then you can also proceed to listen to the neck for any carotid bruit bruise and, and any sort of radiating murmurs, although this would be a bit more evident towards your uh differential diagnosis when you do a chest examination. So I'd say, you know, start distally and move up. Um and each part do your look feel do so now you can move on to a chest examination. So looking from the front to the back um on the front, uh you look for any scars. Um So whether it's got a midlife soy or got thoracotomy scar, um any sort of chest deformities like, you know, uh uh uh peus excavator wall or the, the one that's pointing in what's I can't remember the name of it. Um Any visible pulsations, any implantable devices, whether it's, you know, um under your left or right clavicle that may indicate you've got a pacemaker, an ICD as well. Um Comment on those, um if you can't see anything to say, you can't see any deformities on these scars, er, or on the implantable devices, then you feel for your er, heart, I guess, uh mainly your uh apex beat and any heaves and thrills. Um People often get a bit confused with heaves and thrills. So, II tend to just remember it as, you know, the heel of your hand is where you feel for heaves and heave is basically sort of um sort of a very large beating of the heart. Um And you put it over your left peristernal um edge and that basically tells you whether or not there's evidence of any right V hypertrophy um for ones of underlying usually respiratory diseases, um just demonstrate that you know how to do it. So just put it over here. And then after that, when you can reassess your thrills, which is basically putting your hands sort of horizontally across all your four valves regions. And that sort of feeling for any uh palpable murmurs, that kind of feels like I personally haven't felt it before, but reading through sort of what other people commented, it kind of feels like AAA buzzing fly in your hands. If you've caught a fly before, I've caught a fly before. So I kind of know how it feels like, but you know, that that's how people describe it. And you kind of feel it at the base of your fingers. So just kind of put it across all your sort of four valve regions and then just comment saying, you know, I can't feel any heaves or thrills most often, the unlikely patient would have really sort of, you know, obvious heaves and thrills because if they do, it means that they are probably having quite a severe sub VV disease that they need some sort of intervention. Um then proceed to listening to the heart sounds. Um start off using your diaphragm first, which is the, the biggest sort of part of your stethoscope. And that basically listens to high frequency murmurs across all the four of er regions and then sort of, I'd say listen to the heart sounds first before you comment on anything. So listen for areas of your diaphragm and then repeat again using the bell and concurrent to that feel for the radial pulse as well. Um to, to, to make sure that what you're listening is also, you know, the, the pulse um after you do you repeat with your bowel, then you can proceed to doing those special tests or accentuation maneuvers, which I will talk about a bit later on. That basically helps you distinguish between different types of murmurs um and therefore different sort of your VV uh pathologies. If you do get a cardiovascular examination station, it is probably most likely you will get some form of murmur because those patients tends to be more stable, um, for you to do an examination and there's no sort of common, um, abnormal heart sounds that you can hear. Um, so I'd say familiarize yourself with the types of murmurs. Um, and what sort of valvular pathology associated with that? Um So I'm going to just talk about the, the, the maneuvers a bit later on. Um, but these maneuvers would sort of follow on after you listen to your heart sounds with the diaphragm and, and the bell. So then looking at the back, it's again the same look for any scars, um feeling for any pitting edema, uh sort of mainly so feel the sacrum if you can't feel any edema, that's fine, you don't need to sort of feel upwards. But certainly there are patients who are grossly edematous and usually in patients that can be as edematous. It's all the way up to the mid thoracic level. You know, I see your patients may be just generally don't just up to the neck. Um And pitching edema essentially is when you press down, they leaf an indentation. Um that sort of just stays there and they don't sort of rebound themselves. So those are pitching edema. Um You then percuss your chest. Uh For example, if you've got pleural Orion, they would be dull to percuss, make a comment on that as well. Then you listen for any crackles that may indicate sort of heart failure um and just use the diaphragm because that's, that's a sort of a high frequency um uh uh sound. So posterior is not much to do really. So we're talking about sort of special tests. This is pretty much the only special test you get in a cardiovascular examination. So after you listen to the front, so diaphragm in the four valves and then your bell and the four valves, you then follow one with your special test um by trying to pick out if you hear any sort of murmurs. This, this is quite a busy slide. Um but I sort of put it in, in sort of bullet points, how I would do it during an ay station um for sort of patient convenience, really, because there's a lot of sort of patient moving forward, sitting forwards, sitting back down, breathing in and breathing out. So it seems a bit sort of, you know, annoying for the patient if they keep doing different movements in different times. So I'd like to start off assessing for any um diastolic murmur to look for is a regurgitation by getting the patient to sit forward first, take a deep breath in and out and then using a diaphragm to listen to the sort of the, the aortic sort of um pulmonary sort of region for any um diastolic murmur. Um And if there is a uh underlying aortic regurgitation, the murmur would be accentuated by taking a deep breath out. Um trying to sort of explain this why. So when you take a deep breath out, your intrathoracic pressure then decreases, sorry, your intrathoracic volume decreases, your pressure increases. And when your intrathoracic pressure increases, that forces um the your, your pulmonary vessels constraint and forces blood back into your left side of your heart. And so any left sided valvular disease. So your, your aortic valves or your mitral valves, any sort of um pathology or var disease, any murmurs there would be accentuated by taking an expiration or breath out. So I tend to remember a sort of r so right sided um murmur would be accentuated by inspiration and a left sided murmur would be accentuated by um expiration. So right side, it's your um pulmonary and your tricuspid valves and your left side will be aortic and your mitral valves. So that's how I tend to remember. Um So after you get the patient to sit forward, do whatever you need to do, have a listen, then you can sit them back again and then you can proceed to listen for any uh ejection sic murmur, which would indicate either aortic stenosis um or a a AAA pulmonary stenosis. Um So, aortic stenosis is the one that would radiate to the carotids. Pulmonary stenosis does not. Um So you get the patient to take a deep breath in, then you use a diaphragm to listen to the chest first. Um and then you change it to a bell to listen to the neck for any radiating murmurs because in the neck tends to be sort of a low frequency. Um So if you listen, if, if you hear an ejection ejection systolic murmur, um you then proceed to listen to the carotids. If it radiates, then you know, this is a aortic stenosis. If it doesn't radiate, then you, you can say this is most likely pulmonary stenosis, then you move on to listen for um any other types of murmurs. Um and I tend to just kind of listen across the balls. And when you hit to sort of the apex region, um with your diaphragm, get the patient to tilt towards their left or roll towards their left and then have a listen with the diaphragm hear for any sort of murmurs and much regurgitation tends to be a pan systolic murmur and then whilst they're holding their breath out, you can then sort of listen um across the axilla to see if it radiates um or not. Whilst the patient is still on the left, you can then also listen for any middiastolic murmur which may indicate a mitral stenosis by using a bell. Um because a diastolic murmur is a low frequency um murmur and it's always pathological when you hear a diastolic murmur. Um So whilst they're still in the left position, then have a listen. So I think this is this is how I tend to do it. So for patient convenience really, rather than them, sort of doing lots of things all at once, especially if you've got an elderly patient who can't really move lots, that kind of limit your patient corporation essentially. So you sit them forwards and you lay them back, have a rest and they can roll to your left and they roll them back again. So this picture just kind of shows where you would listen to your, uh, uh sort of heart valves and, and potential sort of radiating murmurs. Um And it, this just kind of takes a lot of practice really to, to get slick with it. But once you kind of get slick with it, it's pretty, just straightforward really. So this is just kind of a slide to show you uh what murmurs associate with what pathology. Uh That's quite that summarized quite nicely. Um And which area of your chest, uh you would find the murmurs is the loudest. Um So I'll probably just put this out there for you guys to have a look through. So I'm not gonna sort of go through that because this just needs a bit of time reading essentially. So after you've done your clinical examination, um the bed end peripheral examination, chest examination, any special tests, you would have gathered all the information you need to present your findings. Um I'd say focus on any abnormal findings you've found um and try to memorize them in terms of say, for example, there's a murmur. Just remember how it sounds like rather than, oh, this is, um, you know, a systolic murmur or a diastolic murmur or I need to remember what pathology it is because that would just disrupt your flow when you're doing the oscopy, uh, when you're carrying out the examination. So I'd say just remember it, you know how it sounds like I tend to just have a, have a, have a sort of a um uh sort of a video clip or an audio clip in my mind of how the murmur sounds, especially when I examine patients and inpatient in the wars. And then I come away from it after I wash my hands and think. Oh yeah, it sounds like that. Basically, it's a, you know, a systolic murmur. Then I try to figure out, oh yeah, it was in this area and stuff. So I'd say just, you know, remember how it sounds like and then come away and then try to, you know, brainstorm what kind of murmur it is and what pathology it is. Um So presenting your patient, I think that's one of the areas where most students tend to panic. Um because you need to make it flow, make it into a story and make it flow. And I suggest using the SBAR format um as how you would present your case to any of your seniors um in a sort of a very nice way. So I kind of type down a bit of a um example here. So um and you can read up lots of examples from, um you know, gee men gives you lots of nice examples and there's some references I put that gives you a nice example as well. So um present to the examiner who the patient is, what age they are, um why you've done your examination um and what was being done today? Um Then you move on to sort of any background, any relevant ones, you know, um if the brief gives you, um you know, whether the fit and well, you know, say, for example, you know, I did a cardiovascular examination on this 30 year old gentleman uh because he's coming with a unexplained collapse. Um and then background history, you know, he's fit and well, he was playing football, but he's got a family history of sudden cardic deaths. And that basically gives you a lot of information on what could be an underlying problem related to his collapse or sudden collapse. Then you talk about your assessment, what you've found so far. Uh I'd say try to present the abnormal findings first rather than the normal ones because that's what's going to capture the examiner's attention um and starts sort of more peripheral than closer. So you got peripheral stigmata of any, you know, um uh you know, any infected carditis and then just mention that if they don't have any of them, that's fine. Um And then you move closer. You're not on close inspection on the chest, so I could hear uh no murmurs or any murmurs and et cetera. Um Sometimes it's also nice to mention that, you know, from the vital signs, they were hemodynamically stable because that's usually one of the things that your seniors will want to know when you present your case just in case we need to do something urgently. Um Once you've talked about who your patient is, what you've done, any relevant backgrounds, what your findings are, tell them what your impression is as well. Don't wait until the end when they ask you the questions. So just say, you know, I could hear on close inspection, I could hear um an abnormal heart sound with an ejection murmur that was louder over the aortic region or, or whatever reason that radiates to the carotids. Um This is in keeping with an underlying aortic stenosis. Um but it could also be a pulmonary stenosis and et cetera. Um mention that to your exam um that would save you time and also uh save time toward the end doing the questioning. But that would also give a good impression for the examiners as well. Then you would always end with um recommendation your own recommendations. So, you know, this is basically to complete my examination, what else you would want to do. Um So whether it's gonna be um I want to get sort of more vital signs uh and A to ECG chest X rays and blood test, look at the counts, any troponin um and any imagings that you would like. So I tend to present it as a SBAR format really. That's, that's quite a sort of niche way to present the case. Um So once you present your, your, your, your findings, um sorry, this slide should be actually before that. So before you present your findings to your examiner, you should already be explaining, thanking the patient and washing your hands for disposing the PPE. Um Once you present your findings, then you will mention the examiner that, you know, I would like you to complete. I would like to do a uh a full clinical history. Um Any other assessments that you left out as well. So this is one of the things. So sometimes when you are rushing through your examination, you may have left out some steps that you feel is relevant and important. Um way down the line. Try not to sort of, you know, like, oh, I need to go back and then go back and do it because that will confuse the examiner and confuse the patient as well that you, they, they're not quite clear what you're doing. If you've left it out quite early on, you can mention to examiner, you know, I would like to go back to the hands to, to, to have a feel of the radial pulse or I would go back to the neck and have a listen to the carotids. But if you are sort of towards the end already, you can also mention this at the end, you know, to complete my examination. I would also like to go back to the neck and have a listen to any sort of radiating murmurs or any Bruits et cetera. And that just basically shows the examiner that even though you've forgotten about it, you, you have sort of remembered to do it that's relevant to your examination towards your working diagnosis. So you can always mention it at the end and then mention any sort of relevant assessment that you would like to do as well. Um I like to just mention what I want to do. Um As I mentioned it before, it usually is sort of additional tests and I'd say be systematic as well, any bed side tests first and then noninvasive and the more invasive one. So do your vital signs when e first um then you can move on to taking a blood test and imaging and stuff. Um You can always mention it. I would also discuss my case with the E as well. That would be a quite a nice kind of, you know, close um your, your, your uh presentation to the examiner essentially. So that's kind of your part that's done. Um The questioning part would be led by the examiner and it usually, it follows on what you have mentioned during your um to complete um say, for example, so I would like to do an E CG and they may actually show you an ECG and get you to interpret there. And then, and they would, they would normally be sort of one question at a time that kind of links together. So it could be an ECG first and then it could be a blood test and then it could be an echo or something and then they would then say, what do you think is going on? Um It usually relates to the pathology of the case. Um And this basically tests your theoretical medical knowledge and what you need to be able to show is that you're able to combine all the information that you've gotten throughout those, you know, examination skills on this questioning uh to try and narrow your differential diagnosis. Um Sometimes a question could be really general. They could just say, you know, can you give me another three differentials if you haven't already mentioned it or any other three investigations you would like to do, it would be nice to tell them why you want these investigations done as well just to kind of justify. Um They can also ask you how we, how, how you would manage this patient. Um If you've already sort of mentioned that I think this is viral disease or I think this is an A CS or something. So obviously, if it's an a CS, it should be sort of an acute um inpatient management. If it's a VV, a disease that really depends on, you know, um, how you would manage a patient, whether it's an inpatient or outpatient, depending on their symptoms. So, a lot of the questioning is really sort of related to what you found. So, just for timekeeping purposes, if we maybe in the next two minutes, we'll try and move on to. Great thanks. So I think if you haven't sort of learned anything from this slide, it's absolutely fine. But I feel like these two last slides probably would be most useful for you in terms of tips and advice and trying to approach a ay station. So you always get four easy points from basic introduction. So wash your hands, who you are, patient name, details their consent. Um And as you do your examination, I'd say narrate the steps that you're doing. So say, for example, I'm going to stand at the end of the bed and do a general examination now and then I will move a bit closer and doing more so closer inspections and tell the examiner what you find as you go as well. So like, you know, radio pass, what is the rate? What's the rhythm? I hear any murmurs mention that as well. If you do find any abnormalities, try and remember it and then try and figure out a bit later on rather than try and brainstorm OK, what is going on right now? Because that would just mess up, uh would just interrupt your flow. And as I said before, if you missed a few things don't panic, you can always mention it to examiner at the end. Um and say, you know, I would like to go back and do this and that if you feel stuck, say, for example, you're trying to figure out what the murmur was. You can always mention to the examiner that it might take a few seconds just to gather my thoughts and then I'll come back to you when I'm ready and that just kind of voids a very sort of awkward silence that no one really knows what's going on. And I've used that a couple of times even in real practice and people tend to really appreciate that because they know that you're thinking. But if you can't think of what's going on, just move on, just don't dwell because you're in a very tight time at the moment. If you're walking the station and you have no clue what's going on, just take a step back, take a deep breath and just go back to basics. So like a systematic approach. Wash your hands. Basic introduction, you get four points, do your look, feel do and then any special tests, any impression and then what you're gonna do to complete your examination even if you don't do the right, you know, thing um or the correct thing to do. You may still pass the station by doing all these basic things just going back to basics if you don't know what's going on. Um, try not to make things up because the examiner would know and just be honest if you don't know, to say, I'm really sorry. I don't really know. I think time man, it is one of the things that was really challenging for me when I was doing my OSC as well. So II personally tried to dedicate 60% of the time to doing what I need to do and then maybe sort of 15 20% summarizing or presenting it. And then the remaining sort of time for any sort of questioning from the examiner, try and familiarize with any marking systems. There's lots of verbal resource out there and, you know, Google Gee Medics has lots as well. Um If you've got time now practice with your colleagues, um it, it, it's all about just being slick and being confident with your, your examinations. Um And if you're still doing clinical placements, you can always ask one of the foundation doctors or any of the, you know, co trainees to do like a formative bedside um assessment with you and just give them like, you know, I've got a coming up to you and can you do one with me um and just get them to pick any patient. It's most likely you will find very interesting cases as well because you're most likely gonna have abnormal findings or inpatients. So these are just kind of the resource that I used when I was in medical school. I used mainly KK medics. I mean, the other two are what I found recently in the last few days that I find really helpful as well. So the second one from slight has got really nice examination techniques with pictures and differentials as well. Um And if you want to practice with your colleagues, you can always use some practice case in stations available on Oy Sense. Um So I think that's the end of it. Uh If you've got any questions, feel free to email me. Um This is pretty much how I am when I listen to the heart. So I'm not great in listening heart. Um But I'm sure most of you would be able to smash the stations just bearing in mind. Common things are common, the people that are not trying to fail you. Um So, so it's all about slickness and confidence really. Um But yeah, I think that's, that's probably what I have to say it. It's just that, you know, it was a stop to, to cardiovascular examination. Lovely. Thank you very much, Tessa, that was a really good run through, really good um You know, well, yeah, useful tips as well for everyone to take forward with them. Um So we'll try and move on to. Um Yeah, we'll move on to the breakout rooms, um, with the tutors. Um, so we've got roughly about 15 minutes left. Um, so we've got three cases, uh, five minutes per case. Um, and I've tried to pop them into the chats as a PDF. Um, but, um, I haven't been able to, to pop it on. Um, so the facilitators should have the cases with them. Um, so if they can just share their screens within the breakout rooms, um just so the students can, can see the cases. Um And I've assigned facilitators rooms as well. Um And then also viewers rooms. Um So if you just go into the room that you've been allocated, um and then we'll come back in, in 15 minutes, er, to, to wrap up the session. Um So I'll leave you guys to, to go into the breakout rooms, right? We'll just wait for the um, other people in the breakout rooms to return to the main stage. Um And then we can, we can wrap up the, the session, just give it a couple of minutes, right? I think there's a couple more breakout rooms that are just trying to wrap things up um with the last case, um, apologies for some of the technical difficulties um if you were experiencing any. Um but hopefully, um those that did manage to get into the breakout rooms, you had a good discussion around the cases um and found them useful. Um But that brings us to the end of the cardiovascular session. So, um, thanks for everyone um, that attended and, uh, thank you Tessa for your presentation and we appreciate all the support from the, from the tutors, um, that, that were discussing the cases in the breakout rooms. So we'll wrap things up for now. Um, if you wouldn't mind completing the feedback when you end the call. Um, so it's in, um, it's in the chat at the moment. Um So, um if you could complete that, that would be great. Um and you'll be provided um an attendance certificate once you've, once you've completed that feedback. Um And yeah, many thanks again and hope to see you next week for the er respiratory examination session. See you all soon.