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And then you need the patients to adequately expose the chest in order to inspect from the uh in, in order to expect from the end of the bed and then uh expose the chest uh and then next slide. Ok. And then general inspection. So uh that from the end of the bed and then uh when you do the general inspection, uh look at two things is the patient's condition, general condition and the surrounding. So see whether patient has any signs of respiratory distress. So whether the patient has a is like breathing rapidly the kidney or any necessary muscle breathing or any paradoxical breathing and then also pay attention for the breathing pattern. Is there any like partly breathing which indicate the patient has an underlying CO PD arthritic airway disease? Uh during uh if the patient is coughing during examination, pay attention, whether is it dry cough or projected cough? Because if it is like more like dry cough and if you hear the fine crackles, uh the diagnosis is more towards the interstitial lung disease if patient is having protic cough and then there is a club in the fingers. Diagnosis is more towards the bronchiectasis and then also uh assess that uh assess if there any chest wall deformity uh because it can be associated with restricted lung disease or os airway disease. And then assess for any asymmetry of the chest wall movement. Uh and uh assess uh any previous pneumonectomy scars or lobectomy scars. Uh And any, is there any chest rate in situ? And then after the look at the surrounding check, is there any sputum poly? And then also check for any inhaler or nebulizer or spacer around the patient which indicate the patient has the small airway disease like CO PD and asthma. Um And then after you finish the general inspection, uh cover the patient up again and then um start with the hand examination before you touch to the hands. Uh ask the patient, is there any pain and then take the both hands of the patients and then uh check for any peripheral cyanosis and then check for finger clubbing. What is finger clubbing? So usually is it like soft tissue swelling uh at the terminal phalanx of the fingers? Uh So clubbing is uh associated. Uh so club uh the so normal people uh when you are there is the angle between the nail and the nail bed. So to check the clubbing, uh ask the patient to place the uh the news of the in this finger uh back to back and then uh check for any uh whether is there any diamond shaped small windows that's called window. So when there is a uh when the patient has a club, the window is lost. So you can't see the window, so you can see the, the picture on the slide. Uh And then, so in uh regards to respiratory system, so clain is associated with lung abscess and palmar bronchiectasis and then uh lung cancer, especially non small cell lung cancer, and then also uh check for any t stings on the fingers, which suggest that patient is a chronic smoker and then check for any joint deformities, uh which I usually see in the rheumatoid arthritis, which associated with the interstitial lung disease. Also check for any tight fingers, any shiny finger like sclerodactyly, which are the signs of systemic sclerosis and crest syndrome again, which associated with interstitial lung disease and pulmonary fibrosis. And uh uh check the palmar surface of the hands and check for any small muscle wasting of the hands, which associated with honor syndromes in the apical lung cancer. Uh So, uh the left side of the screen is showing the left hand has a small muscle wasting and there's a thinner atrophy. The right hand, right hand is the normal. And then the the photo on the right side is showing the rheumatoid hands, uh symmetrical deforming polyarthropathies of the hands. Ok. And then move on to the wrist. Uh So, uh palpate the wrist uh to see is there any tenderness uh which can be seen in HP OA uh hypertrophic pulmonary osteoarthropathy, which associated with lung cancer. Usually there is a triad uh, finger clubbing, uh, uh arthropathy of the last joint and also, uh periostitis, uh, which not very common. Uh, and then, uh, check for any signs of carbon outside retention. Uh, so check for assess for pounding pulse and then assess for flapping tremor. Uh, so to assess the flapping tremors, uh, ask the patients to extend out their hands and then spread the fingers, uh and then ask them to, to flex the wrist and, and ask the patients to close eyes. So, ideally, it should be assessed for like 2030 seconds. Uh and then uh check the extensor surface of the forearms to look for any psoriatic skin rashes or any rheumatoid nodules, which are associated with uh pulmonary fibrosis interstitial lung disease and then move on to the face. So I check if there are any facial plethora, so which are associated with polycythemia uh in CO PD. And then also check for any uh malar rash. Uh because all these autoimmune disease can be associated with pulmonary fibrosis, interstitial lung disease. Also check for cushion noise features which suggest the patient is on long term steroid use and then uh assess any signs of honor syndrome, like ptosis of the eyes or, and the neo of the eyes and then assess for the con pa and then as the mouth for central diagnosis and any microstomia, which again can be seen in systemic sclerosis associated with interstitial lung disease. And then also you can check for oral candidiasis. Uh if the patient is using the patient has the underlying co PD asthma and then using the steroid inhaler very frequently, you can see the uh oral candidiasis. And then um and then after that, uh proceed to the neck. So in the neck exam, we assess for JVP and the trachea. So uh to assess the JVP, uh ask the patients to turn slightly onto the left side and then uh look for the double waveform position of the internal jugular vein. So normally I GV lines between the two head of the sternal matric muscle. So uh so measure the vertical distance uh from the ST angle and the highest point of the double wave from uh normally, it should be more than three centimeter. Uh So if the G VP is elevated, it suggests the patient has uh right heart failure and then it can be right heart failure and called pulmonale. And then after and then move on to assess the trachea. Uh before you see the trachea want the patient because they might find it a bit uncomfortable. So I check for trachea deviation. So normally uh effusions and the new moor, they will push the trachea away, but trachea with deviate towards the site of fibrosis and then collapse. So to assess the uh to check the trachea deviation, uh place your index finger and the ring fingers on the east side of the clavicle and then use your middle fingers. Uh And then as uh check whether if the trachea is in the midline. And then after that, assess for quick external distance uh to check for, is there any tricky attack? So place your index finger at the inferior border of the quick, quick white cartilage. Uh and then measure the distance from the quick white cartilage to standard, not so normal, uh normal distance is 3 to 4 fingers with it is below three finger weight. It makes the patient has a hyper expended lungs like COPD. And then after that, uh start the chest, examination stuff from the anterior chest. So expose the patients again and then uh inspect closely, look for any scars and then ask the patients to raise the arms uh and then check the side to make sure you don't miss any scar from the side. Uh and then feel the ap so normal AP should be at the fifth uh inter space mi line and then check for any signs of uh right ventricular pressure overload, like parasternal heaving, palpable to uh so you when you check the parasternal, he uh you will feel that your hand is lifting up. It's because of the uh pressure overload from the right ventricle and then um assess the chest wall expansion. So, uh normally in the anterior chest, uh we assess the chest wall expansion for the upper chest and the lower chest. So for the upper chest, uh place your hands uh uh in the either side uh of the chest uh along the uh along the sternum. Uh and then uh either side of the sternum and then ask the patients uh to breathe all the way out and then take a deep breath in and then assess whether your hands is lifting equally uh during inspiration. And then for the lower part of the chest, uh please uh the rub your fingers are uh are on the either side of the chest wall and then dr into the middle and then keeps your tens off from the chest wall, uh chest surface and then ask the patients to take a deep breath in and then assess whether your fingers are moving in equal distance during the inspiration and then after that, uh move on to percussion. So, uh for the percussion, uh normally we per uh in the two apex uh in the, in the AP CS and then uh three points and uh three points each side anteriorly and then two points each side uh naturally. So uh to uh for the uh for the apex uh just uh per the rightly onto the clavicle. Mhm And then when you do the precaution, uh make sure that you pres uh uh like s shape uh for the comparison so that you can compare each side. Uh and then um the normal percussion note is a resonant. So uh when it becomes abnormal, it uh like pleural effusion, it will be still need. But if there is a consolidation, uh the pression note will be dull percussion node. But if there is a a trp uh like pneumothorax and emphysema, it will be hyperresonant. And then the next is auscultation. So, uh when you do the auscultation, uh make sure that you listen uh the one who respiratory cycle and then ask the patients to take deep breath in and out through the mouth. And then uh it again, the compare each side turn like the s shape. Uh So when you uh Oscar take the patient uh pay attention to the quality of the breath sound and then also character of the breath sound and then uh also assess, is there any additional sounds? So, uh normal breath sound is a vesicular breath sound. So the inspiratory is uh inspiratory phase is more prolonged than aspiratory phase. Uh And then uh if the patient has consolidation, so it became like high patient sound. So it called bronchial breath sound. Is it the sound like when you are similar to when you listen to uh when you listen over the trachea? So inspiration and iny face is it the will be equal? Uh But there is a gap in between and then uh pay attention whether breath sounds are equal in the both sides or whether it's a breath sound reduced in the equal or is a reduced and then uh assess for any additional sounds like crepitations or wheezing or any rap. Uh So if you hear the crackles, ask the patient to cough, uh if the crackles are clear with coughing, it means uh it's a and then there is a, usually there is a uh fine crackles and the cost crackles. So fine crackles are like velcro sound is associated with interstitial lung disease, pulmonary edema. Uh But in bronchial disease, uh it's like more like cause crackles. And then um uh if the patient has a small airway disease, uh you can hear the wheeze and then after uh and then move on to vocal resonance. So um ask the patients to say 99 each time when they feed the stethoscope on the chest. So, uh when there is a increased density in the lungs, like consolidations or tumor, the vocal resonance will be increased. But when there is a air or fluid in the pleural cavity, vocal resonance will be reduced. So, and then um move on to the posterior chest and then uh examine the cervical lymph node. So uh when you examine the lymph node, cervical lymph node, uh place your hands uh on the uh east side of the neck. But when you examine uh just examine one side at a time, it's not to compromise the cerebral blood flow because of the carotid artery compression. And then after that uh ask the patients to sit upright and then fold their arms across the chest and then uh repeat the same sequence of the examination, inspection palpation, precaution auscultation uh like the anterior chest. So repeat the same, same sequence. And then after that, check for uh any sacral edema and then check the legs for, to check for any pedal edema which suggest the signs of right ventricular failure and call and then look for any rashes or any signs of DVT. Uh So after you finish the examination, uh thanks the patient and then help them back into the comfortable position and then offer help to redress and then uh wash your hands. So, uh and then uh you consolidate the findings and then turn to the examiner and then present the examiner that you want to complete the examination, like for looking at the parameters uh looking at the chest X ray and then obtaining more relevant history depends on your clinical uh examination findings uh during uh when you are presenting the examiner, don't look at the patient. Uh So this is the example of my presentation. So the first point is to present uh the positive findings and the relevant negative findings uh to support your diagnosis or differential diagnosis. So, for example, this patient has a finger clubbing and then uh bilateral fine crackles on auscultation which do not change with coughing. So, in keeping with interstitial lung disease, uh other differential diagnosis of bronchitis and underlying malignancy. And the second point is to present whether patient has any complications of this disease. So present, the patient has patient uh is not in distress and not in is patient is not cyanotic. And then so and then no signs to suggest uh common side retentions and the pulmonary hypertension. And then uh that point uh is to present the finding that support the possible uh that support the possible underlying etiology uh of the disease. So, with regards to etiology, patient has the symmetrical deforming polyarthropathy, mainly affecting the hand. So which suggests the diagnosis of rheumatoid arthritis complicated by pulmonary fibrosis. Ok. And then uh when you press out about the investigation, always start from the bed side and the simple test uh like maybe peak flow meter, peak flow uh and then uh routine blood test and then chest X ray move on to the chest X ray and then um and then ABG to assess the severity and the respiratory function test and the CT scan to confirm the diagnosis. So, so um my advice is always be nice to the patient. So always remember to explain and inform the patient each and every step as you go along and then always ask about the pain before you touch them. Uh And then you also need uh a bit of time management, especially for the respiratory examination because there is a a few extra step compared to the other examination. Uh but just keep practicing and then memorize the steps. So you'll be fine. Uh, you're able to adjust the time if you don't finish on time, that's fine. Don't panic. Just, uh, tell the examiner what else needs to be done. So, the examiner, I appreciate, you knows what you are going to do, you know what you need to do. Uh, and then the important thing is, uh, do, uh, do not ever, um, make, make up the signs uh be honest, just present whatever that you uh gather in the examination. So uh it's just all about slick uh slickness and all be confident and then keep practicing, you will be fine. OK. So uh this is the end of the mind uh session. So this is the references and for the recap, if you want to learn more about the technique and I want to watch the video, this is the link from the Kiki Medics and then Oxford. And also if you want to practice the key with your friends and you can practice from the a sense as well. Uh This is my email address. So if you happen to be in Edinburgh and then if you want to practice the case and the formative assessment, feel free to contact me. I'm more than happy to help. OK. So this is the end of my uh session. So if you have any questions, feel free to type in the chat box, I try my best to answer. Yeah. Does anyone have any questions? No? OK, nice. Thank you. E and Yeah, thanks for all of you. Yeah. How's the, oh, here we go. There's a question uh uh from Tunisia. I think she's typing what we do. Anterior. Yes. Normally, uh We have to do both anteriorly, uh both anterior and posterior. But if you ran out in time, yeah, it's just so the important thing is just keep practicing. So you'll be fine when I first started doing. I also feel that that it's not enough. But after you practice, uh you're able to adjust the time, pay more attention to the posterior chest because you pick up uh you're able to pick up more signs posteriorly, but you have to do both. But if you really ran out of the time I start from the posterior, definitely. So trying to finish in light, uh I think it's like 78 minutes so that you have to present with the examiner as well. So just keep practicing, you'll be able to adjust the time. Yeah. Yes. Yeah, thanks again. Um I know you probably got a night shift. So we won't, we won't keep you. Sorry because I was quite sleepy. But thank you very much for the um the comprehensive run through. And uh yeah, some really useful tips for everyone for their ay. So um yeah, it was very valuable for them. Um So we can, we can now move into the breakout rooms with the tutors. Um, so it's roughly half past now. So you've got about 30 minutes to go through all of the cases. Um, and I can't post them into the chat. But your facilitator, they'll, they'll have the, the PDF and they can share that on the screen within the breakout rooms and then you can, you can go through them, um, as a group. Um, I'll quickly pop, um, the facilitators and their assigned room number. Ok. So if you, if the facilitators can look at which room I've just assigned them to. And on the left hand side, you can see a tab called breakout sessions. Um, if you click on that tab and then just go into the room that you're assigned to, um, and then I'll just post, um, which rooms the viewers should go to as well. So there we go. Um, so if you can all go to your rooms and let's say we'll, we'll come back, um, at, um, if, well, if you finish the cases, you can come back earlier to the main stage. Um, or, um, yeah, we'll, we'll reconvene at about 8 p.m. That'd be great. Ok, so then our heads off now. Thank you all. Have a lovely evening. Thanks. Thanks will. Bye bye, bye bye.