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Can, can everyone hear me from the me chat? Ok. Hello, everyone. Can everyone hear me? Ok? From online? I can hear you. Ok? No, that's fine. So welcome everyone to the session. Ok. It's an in person session um for most of you here and anyone online we try and er accommodate to you as well, but welcome everyone in person, both here in Cardiff and also in Bangor. Um The session today says on the screen that we're going to also do gi but for time purposes, we'll cover cardio and respiratory and if we can get around to, to gi then we, then we will also cover it. But our main priority today is to go over cardio and respiratory exams, go through how to, to do one efficiently. Hopefully you'll watch the um online videos that we sent to you all as it's more just to build from what you learned from those. OK. So next slide that's OK, we'll show you, we'll give you a demonstration if you haven't. OK? Just to show you how to do one efficiently and we'll go from there. OK? Um So these are all the er videos that we hopefully, er, wanted you to watch. Um today, the objectives will be allowing you guys to understand the key concepts and components about doing a cardio and respiratory exam efficiently and to get all the marks that you'd need to in the actual exam, um we'll be practicing with our colleagues, so we'll hopefully have you all pair up um and practice with, with someone else and then we'll all go round as the, er, invigilate, invigilate staff and basically give you tips and tricks of how to do them better or things that you could do differently. OK? And then we'll go over things like spot diagnoses and things the examiners could basically give you and expect you to, to pick up and know and, and see clinical signs. I can't promise whether they'll give you actual actors on the day. Um But at least knowing common signs and uh even symptoms allows you to, to excel in the actual listing. OK. Next time. So this is a uh my template of how to approach every examination. This is no different from a lower limb exam to a cardio exam. OK. So introducing yourself, explain the examination, you're going to do gaining consent from the patient. Offer a chaperone. Even if it's something like a hand exam, I would still offer a chaperone. OK? It's just good practice. And the principle is if you are going to be putting your hands on a patient examining them, a patient should at least be given the option of having someone there to act as an advocate of them for them if they're uncomfortable at all, washing your hands, that should always be done at the start of an examination. And at the end, just get into that habit of always doing that motion. As soon as you're even starting a history examination, you're washing your hands and at the end as you're concluding, washing your hands as well. Ok. And then finally, I would also, before even starting, just asking, is the patient any pain or discomfort? Ok. If they do say they are, then I would often kind of accompany it with. Ok. So I'm going to have to examine you. Ok? And then after I finish the examination, I'll see if we can organize getting you some pain relief as well as well. Ok. So if I had Sara, who was my patient and I wanted to explain a cardio exam, I say hello. My name is Doctor Fitzgerald. I'm one of the foundation year two doctors, I've been asked today to do a cardio exam. What this will involve is me having a look at you uh from the end of the bed, having a close look at your hands, your face, your chest, I'll be feeling the pulse in your arms and also I'll be having a listen to the heart as well. I'll explain everything as I go along in the exam. Does that sound? Ok. Yeah, that's fine. Yeah. Do you have any questions for me at all? No, at all? No. Do you want me to have a chaperone present for the examination? No. Ok. Are you any pain or discomfort before we start the exam? And that should just be the general approach that you have for most of your exams? Ok. It's on to the next side. Uh, first question. So, is it best to always ask if they would like a chaperone even for a cranial nerve exam as well? I would because as, as I said before, if you're going to be examining someone, it's always best practice just to offer that chaperone for a patient. Ok. So this is the general approach I would have for a cardio exam. So your inspection at the end of the bed, then you go into your more focused exam. So that's having a look at the hands, feeling the palms of the hands, feeling the pulse, having a feel for temperature working your way up. So feeling the brachial pulse, then I would check for your BP, having a look at your um your, your face, your neck going onto the, the chest. So that would be first having a feel for the apex, beat heaves and thrills. I'll go through all of this with you um having a listen to the heart valves. OK? And then also doing your final things like listening to the uh the bottom of the lungs and also looking for any signs of edema. Ok? And then once you've got to the end of an examination, ok. For a cardio exam, things I would offer would be a respiratory examination, BP of both arms if you've not already said it during the exam, 12 lead E CG. And then these are things that you can and uh don't include, I know the geeky medics, one says that you would offer to do a peripheral vascular, peripheral vascular examination. Um If the gi humans video includes that, then I would include that as well. But again, it's up to clinical preference. And then a few other things that I sometimes tack in is a urine dipstick. If um you're looking for any signs of um proteinuria or um conditions related to the kidneys that have a, a component related to the heart as well. Um And then other investigations depending on what case they've given you. But it, the most important ones I would say is your respiratory exam, your E CG and your BP. OK. Onto that. So I'm going to ask my trusted assistant assistant Sara to be the patient. OK. I'm just going to turn on my camera so everyone can see me. Can everyone see me? OK. OK. That's the side. Just one time we'll see if we can get you a seat. OK. Is that going? Ok. Being on coming by the way? No, no, no. OK. So can everyone see me. Ok, from there. Ok. All right. Ok. So first things first wash your hands. Ok. So, hello. So my name is R Fitzgerald. I'm one of the uh foundation of two doctors. Could I just check your full name and date of birth? Um, of 2000? So good to meet you. So, um, how old does that make you uh 24 start there? I'm gonna ask to perform a cardiovascular exam. It's an examination of your heart. So what involves me having a general look at you. I'll be having a closer inspection of your hands and your face and your neck. I'll be having a listen to your heart and then a few other kind of special investigations or special tests that I do during the exam, I'll explain as I go along. Does that sound ok. Do you have any questions at all about the exam? Do you want a chaperone to be present during the exam? Because it will involve you having to get down to, uh, on the arms that you've got. So it may be quite a personal exam to you. Would you like some present? All right. Thank you. Ok. That's fine. Do you have any pain or discomfort before we start? Yeah. So at first I'll just take a look at the end of the bed. Just take a look at the end of the bed. Look for any AIDS that are around, whether she's on any medications whether the star looks generally well on herself or she does. So I'd like to have a closer look at your hands if that's all right. So having a look at the fingernails, looking at the back of the hands, that's fine. You just turn over your hands for me. That's really good. So I'm gonna feel the palms that's fine. Just gonna check is a good uh a refill. Why I have a few of pulses now. So at this point, I would say about to check for 15 seconds. Ok? And then I times the number by four in the actual exam. I'd advise that you do check for 15 seconds, get a good pulse and then up to your 15 seconds and then basically work out your head pulses. Um But for this instance, she has a, a good character and volume of the pulse and the rate is normal as well. OK? I then like to check both sides. So check for any radio radio today. That's fine. So that's all good. And then I'm going to be checking for a collapsing pulse. And what this is going to involve is me having a feel of your pulse and then lifting your arm. Ok. Quite briskly. Do you have any pain in your shoulders or before I do that? Ok. Just having a feel? Ok. And what I normally do is I wrap my wrist or wrap my, my pal of my hand around the wrist. When you're feeling for a collapsing pulse, it's very unlikely that you'll get one in the day, but you should feel a rush of the blood come out of the pulse itself. Ok. So when I lift an arm, her pulse is still strong despite me doing that. Ok. So that's fine. So then I'm gonna just move check temperature. So just having feel fine. So temperature is all good. And can I feel the pulse in your arm? So you break up both. That's around here. So just have a good feel. Yes, I've got a good rate at this point. I'd like to get BP on both arms if that's ok. Ok. So now it's kind of a question to look at your neck. Ok. So preferably I'd like the bed to come down to 45 degrees. Ok. In this instance, we can't, can't do that, but that's fine. I'd have a look at the J BP. So you've got a, you've got your sternomastoid muscle which sets here, your J BP should just come up around her. We can't see that. Well, so because she's not laid down, um, and it is quite difficult but, um, that's where you're sort of looking for just around her. Yeah. Oh, here. Ok. So what I would do is I'd assess generally at the end of the be whether she does raise GGP. And then I would offer to do that. It's quite a painful step to do especially if you do it correctly, you have to properly push in and the level up. So I would just offer in the exam if the examiner does want you to do it and how you should do it is you just go underneath the boob page. OK. And then you push in. OK. I know it is quite uncomfortable and then it brings up the JVP and an abnormal result is anything above four centimeters. So how you measure a JVP is from your sternal angle, which sits just about here, it's going up vertically and wherever the, the vein ends up. So we just gonna go out slash. So from here. OK. So you would go from the sternal angle. Yeah. And you would go up and where the, the vein sits or finishes where you see it eventually goes into the neck itself. That's where your GPP has basically ended. And you'd probably measure on that. You say that you'd like to measure on the day, but in Sal's case, but we're not going to do that cos I'm not expecting it to be normal. OK? And then I would have a listen to her neck, ok? Just listening to any bruises at all. I would always listen before feeling because if she does have anything like a um uh a stenosis or if there's any um uh bru there, then what Cardiff would like you to do is listen first because if you do feel and then there is anything causing that abnormal uh life, you could end up sending a clot. OK? And that can cause things like strokes in patients. It's the best practice. You listen before you feel OK. All right. Then have a list uh how I feel. Uh I'm then gonna have a closer look in, in your eyes and your, in your mouth if that's OK. So, so if you can just bring down your lower eyes for me and just look up eyes, just looking for any color in the eyes. And then I'm just gonna have a closer look in the iris. I'm looking for any corneal arcus. OK? And then if you could just open your mouth for any eye for me, that's it and have a look for any kind of changes in the roof of the mouth at our start to lift her tongue to the roof. Fine. OK. And I was gonna be a nice teas going to show me teeth. So I'm looking at her dentist and making sure it all help. OK. So at this point, I'll go on to the inspection of the chest. So I'll just have a general look at the chest to see if there's any uh chest deformities or any scars that I can see. I would then go into a more closer uh palpation and auscultation. So, are you happy for me to, to keep going? Ok. So that's fine. So what I'm feeling for the apex beat. OK. The apex beat its just underneath the intercostal space, the fifth intercostal space, midclavicular. OK. So I feel like this. OK? And I check to see if there's any displacement of the apex beat. OK. When I'm checking heaves or thrills, OK. Heaves, I feel with the, the palm of my hands. And this is to check for any right ventricular hypertrophy. OK? So heave, you'll feel the pulse, the pulsation from the heart coming through. OK? And then fills those are any like murmurs that are almost loud enough that the uh transmission of the sound is actually coming through to the uh chest itself. So how I would feel is with my three fingertips going just over the bowels, I go aortic Hormon, I cuspid mitral. OK. At that point, I've had a general uh feel of the different parts of the heart that I'd want to. And this is where you go on to auscultation. I have a listen. And when you're listening, I would feel the pulse at the same time to see which one it is, whether it's the um uh to make sure that you're getting which beat is the right one. So I'd go over the aorta, right? Bicoid. OK? And then I do the same thing with the other side. OK? So you just repeat it, but on the other side of the valve or the other side of the side, OK? And at this point, I would do the accentuation maneuvers and there's only two. Ok. The first one would be listening over the, um, aortic, I believe it is. Yeah. Um, and then I'll ask Sarah to come up, ok? And then take a deep breath then, and then breathe out. Ok. And then ask her to hold it there and then I'll basically be listening for any kind of accentuation of the murmur itself. Ok. The way I like to remember them is if you've got a problem with your right side, if you've got a problem with the right side of your heart, then inspiration is gonna make it louder. The reason of the way I like to remember that is your right side, sends it up to the lungs for it to be perfused with oxygen. So, if you've got a problem with your right side and when you breathe in, it's gonna make that problem worse the most likely because it's gonna cause a back pressure of the blood. So it's gonna make the m the louder and then on your left side of your heart, it gets louder if you expired. OK. So an expiration when you breathe out, that's when you're going to hear your left side and murmurs louder like mitral mitral stenosis, all of those aortic stenosis. Ok. So once I've had a list and I've done that accentuation maneuver, I would then do the second accentuation maneuver, which is placing the er stethoscope just where the mitral valve would be. Ok. Uh, as I leaned over onto that side. Ok. All right, let's ok. Ask her to lean over onto that side. Ok. And then to ask her to take a deep breath in and then a deep breath out. Ok. And then listen for any accentuation of the murmur. Ok. So then we've done the part of the exam which involves the heart. You would then just go on to listening to the bottom of the lungs. Ok. Check for any sacral edema, which sits at the top part of the sacrum. Ok? And then checking the legs and just basically pressing down to look for any edema. Ok? And then that, that would conclude the exam. So I would wash my hands. Ok? Say, ok, that completes the examination. So, ok, I'm just going to speak to uh the examiner about what I found. Ok. And can I just check your name and date of birth? Ok. Just so I get it right to the examiner, most of them. And I always like to do that on my exams because it's still fine to ask it. But it always looks very slip when you're explaining it to the examiner saying this is Sara, a challenger and date of birth or 23 years, 23 year female. And then you can go into your spiel about what you found on the exam. So in this case, I've examined Sara a 23 year old female who presented with cardiovascular symptoms. I don't know what the station was saying. Um On examination, she looked genuinely well at the end of bed, uh there was no peripheral stigmata related to cardiovascular disease that I could discern on my exam. Uh There was a normal JVP. Um on the feeling of the heart, there was no displaced apex beat. I couldn't feel any heaves or thrills and listening to all four, all four parts of the heart, I couldn't hear any additional heart sounds and the rest of my examination was normal. So this would conclude as a normal cardiovascular exam, we will have different ways of explaining it. So long as you add anything of a positive sign that you found that's good. But if it's a normal cardiovascular exam, then that's how I would phrase mine. OK. So I've gone through it. Ok. So I'm gonna show you kind of some spot diagnosis of things that the examiner could give you on the day and these are things that you should just be able to easily recognize. Um And the thing that I would sort of tell you to be aware of is if you have a patient coming in on the day, you have to remember they're going to bring in a patient that's stable for you. Ok? So it's very unlikely. Ok? Don't quote me on this, but this is my view on the case. They're not going to bring in someone with a very severe infective endocardiosis that has a murmur and looks really unwell because you can't bring in a patient like that. So it's going to be someone who comes in with something that's stable and chronic that if they want you to pick up signs on the day, then you would be able to pick that up. So that would be like your heart failure patient coming in with pitting edema that might have a murmur as well. Um or it might be for your respiratory exam, your patient who comes in with COPD and they're very wheezy, but that's their normal. Ok. So just bear that in mind the only time when they'll start testing you on things like infective endocarditis, all those things if they start showing you pictures of what you see on the exam and then that's when they might start getting you to pick up on the dose. Ok. So we'll just go through the spot diagnoses if that's all right. OK. For this, we're gonna go 15 seconds each. So kind of like a pop quiz. I know it's going very quickly, but we will basically, once you've all paired up, we'll go round and if there's anything that you want to go over or anything that didn't make sense, all of us can basically, you know, walk you through it and if there's anything that you want us to explain again, we, we can OK. So if we just move on 321 OK. So any shout shout outs, what does this look like? Good splinter hemorrhages onto the next, it's gonna be very quick, so great on to the next. Ok. So clubbing the best the clubbing specifically is when you get that distortion of the nail bed. Ok. And there's different stages of clubbing and if we go on to the next slide, I'll show you what those stages are. OK? So when you start seeing that loss of the shams win the window sham loss test, which I know Cardiff sometimes examine you on. I personally don't do it in my exam. Cos I like to look for clubbing, but uh I think they sometimes do expect you to assess it. So that's another thing that you can do. Um how you assess that is basically you put your two fingernails together like this, like you're almost making a love heart but not quite. And then you're looking for any loss of the window and the effect that you can see between those. Ok. So that you would pick up if you had a stage two clubbing. But the best way to actually pick it up is if you feel the nail itself, if you feel any loss of that, if you feel it's like fluctuant or it's um spongy, then that can be an early sign of clubbing. So another thing you can do is actually feeling along the nail bed to feel that kind of fluctuation. Ok. So Yeah, the window Sharos test. Yeah. So there's lots of things that cause clubbing. Ok. Um The biggest things in, in cardio is, is like your cyanotic heart disease. But again, if you pick up clubbing, it can be related to an array of different kind of conditions. Ok. And obviously infective endocarditis is one which uh always comes up as a, as a cause as well. Ok. Any ideas what this is? I'll give you the history first. So it's a patient who says these are painful. Ok? And they're on the pulps of the fingers. Ok? Any ideas? Someone in the chart said Janeway lesions? Ok. I'm glad you said that because there's two, there's two different ones for infective anti. So there's the Janeway lesions and what are the other ones really good? Ok. So how do you tell the difference? So, the best way I always like to remember them is I always call them Owler nose because if you press on them, someone will say, ah, Janeway lesions, they won't be painful. Ok. So Osler's nose, they'll often describe them as being painful. Ok. And I always remember the pa pa, pa, pa pa, so painful on the pulps of the fingers or the palms. Ok. And they're often purply in color. Ok. And you can sort of see they've got kind of like a purple tinge to them. Ok. Yeah. So, no, that's the best way to know which one is which because someone will say, ow, that's fine. And you often see them in infective endocarditis. Yeah, we'll move on. Ok? And these are the other ones. So Janeway lesions, you can't see them that well. Ok. But you've got one here, you've got one here, one there, one there. So the way you would describe these in the exam is they are erythematous. So they are red, OK? And they're macules. So the difference between macules and papules are macules are not, they, they go along the skin, OK? They don't have any raised po portion to them and then papules actually have a raised portion. OK? So erythematous macules literally just describes something that's red and it's a long surface. If you say they're kind of scattered over the palms, that's a fairly good indicator. It could be something like Janeway lesions. OK? That's fine. Any ideas what this is? The hands are a bit difficult to see, but the right has a very distinct look to it. Anyone heard what xanthomata are? Yeah. So what conditions do we get? Xanthomata in? Yeah. Really good. So, hypercholesteremia. So if you have any high fat in your, in your body, you can get these. This is quite a severe oh If you just go back, this is quite a severe one, the one which is on the shin and it's very focal. It's, it's easy to pick up in the finger webs here. That's where they're getting the lipid deposits. So quite commonly fats and lipids do like to deposit in areas that have the skin creases. That's where they normally like to collect. But occasionally you can get these focal depositions of it, which are much easier to spot. Yeah. So on to the next. Ok. I don't know if we'll be able to show the video we can try. Is it working? Yeah. One sec. When does anyone have any questions so far? Anything that he wants me to go over at all? No. Can you see that? No. Oh Can you see that now? Uh There we go. Yeah. Wait, let me mute because people here know the OK. So do you see just where the nail is just at the end? Do you see these like pulsations just under the nail? So this is something called Quink sign? OK. And I've seen a few patients on a cardia ward with this. So it's not as uncommon as you think. I don't know if you work on a cardio ward. Have you seen it a few times? Yeah. So you do actually pick up these very subtle signs on the fingernails. OK. And it's a very classic sign of aortic regurg. Yeah. Um So the under the fingernail, you will see those little pulsations and you just see it almost like dip every now and then. So you have to pay very close attention to see it, but you can see them. OK. That's fine. So this was something I really wanted to quickly cover with you all the slides. The slide has a lot of information but the things I want you specifically just to, to note is what's the difference between petite? I purpura hematoma, ecchymosis cos you read about it all on the, the um, textbooks and a lot of people, it's like, I just don't know what the difference is. You'll see a reference a lot. Petite. I are really small. Ok? And you see them and the small areas are bleeding under the skin. Ok? But they're sort of just scattered. Purpura are collections of those. So you see them all bunched up. Ok? An ecchymosis is just a bruise. Ok? And then a hematoma is where you've actually got that collection of blood that's poured into almost like a, a little lump. Ok? And that's just the difference between all of them. So it's just a really good thing to know what the difference is and, and what they all look like. So you can see that, that these like really small dots all over these erythematous macules, we'll call them and then the pura a collection of them. Ok. So they're a bit more bunched up. Ok? Any ideas what this is? Yes. Really good. So this is Malar rash or Mala flush. Ok. Um You see they've got this er erythematous distribution just over the nasal bridge and coming into the cheeks. Ok? And they've also got it collecting around their chin. Ok. You see this very commonly uh not commonly, but you do see it in patients with aortic stenos, uh sorry mitral stenosis. Ok. So I always remembered Mala for mitral. Ok. On to the next. And these are all your other causes for it. So it's very commonly associated with endocrine conditions um and kind of more, more generic conditions outside of that. Ok. Any ideas what this is really good corneal arcus. So you get this white ring around the iris, OK? It's, it can be either white gray, er or some not often bluish, but it's more this white gray color that you have around, around the eye. OK. That's fine. So this is how you assess the JV pain. OK. So you go off where the sternal angle is, just go back. If you go off the sternal angle, you go up to where you see the JVP. So the JVP kind of goes through where the stern of mastoid muscle would be in terms of the heads and then you just measure up. So it's not a long here, it's actually going up vertically. That's why we always stress about the patient being at 45 degrees. It's not to accentuate the JVP as such, it's actually for your measurements to be more accurate. So it's kind of standardized across the board. Um Yeah, on to the next. So this is um the grading that we use for murmurs. OK. My advice is in the exam is if you can pick up a murmur. Ok. All I would want any student and even junior, uh, even an F one or F two to be able to pick up, which is a, a leap in itself is if you can pick up a murmur, if you can at least say whether it's a systolic or diastolic murmur, you're already doing better than 95% of people I wouldn't get caught up in the ideas of is it ejection? Systolic holosystolic? Because that's when it, it does become a bit more complicated and you really have to have that good listening. E but if you can tell what the difference is between a systolic and a diastolic that's already doing really well. And the best way you can tell with that is if you're actually feeling the pulse at the same time because that will tell you when the pulsation is going and when it's actually a systolic beat and when they're in diastole. Ok, that's fine. Um So we won't show the videos now for the, the murmurs, but I do advise you to go away and listen to them. Ok? I would run the video at half the, the speed, ok? Because that's how I listened to them when I was first learning them and it really tells you exactly when you're expecting to hear the beat. Ok. So it means that when you've got it at the normal speed, you really know exactly what you're listening for and where you're hearing the beat. Ok. I had this slide on just for you, for, for yourselves just to sort of, you know, what the different investigations are, complaints all of these. But as I said, the most important thing that I would want you guys to be able to do is at least if you can pick up whether it's a, a murmur for one. If you can pick up a murmur, that's really good. If you can pick up whether they have it in systole or diastole, that's really good as well. OK. So, OK, so this is what I was saying before. Don't ever complicate it. They're not gonna give you some very, very unwell on the day. They're gonna give you someone with someone with a chronic condition or if the person is a uh a patient who's not got any pathology, any signs, then most likely they'll assess you in the station on other components. So they'll say they've come in with XYZ. What do you want to do? And then you just have to go off the scenario they've given you then. Ok. Um So these are the kind of ideas that I thought that they would, if they were going to give you a patient, they could, they could bring in on the day. So someone with hyperlipidemia with the, the signs that we've sort of shown someone who's got a stable murmur that you can hear um, someone who's got chronic heart disease that you can pick up whether they've got pitting edema or, or a murmur to go along with it. Um, and occasionally they might also bring a patient with af, or something like that. That's got a irregular, irregular rhythm. Ok. Before we move on to the next part, does anyone have any questions? Anything that they wanted to go over again? No. Anyone online that wanted to ask anything? Yeah, that's another thing, a cardio ward, they will have loads of patients with murmurs. If you go to any um, doctor on a cardio ward and say if you've got a patient who's got a good murmur to listen to, then they'll have tons that you can choose from and that will really help just picking up, you know what murmur, what murmur should sound like you can even see if you can try and grade the murmur and that, you know, will help with your understanding about grading. But that is taking it to another stage. I would just try and pick up on what murmurs should sound like in general and you're already doing well. Yes. Some metallic valves as well. You often hear that click. So it's something II would comment on an exam if you just hear something that doesn't sound quite right. Just comment on what it sounds like you won't be wrong and you might be offering the examiner that you've actually still heard something you're acknowledging it and often that click is a metallic valve that you're hearing. Ok? And that's why it's really good to look for any scars that they have where they've possibly had the surgery for the metallic valve. So the most common scars that you get, you can have a stenotomus scar. Ok? Um That's for anything like an emergency surgery they could have had for a cardiac tamponade or um, any kind of intrathoracic surgery they may have had um you can have lateral scars kind of along the axilla. Those quite commonly can be for things like chest strains or if they're going through a different route for something like an ICD more so than not, you do get scars for icds and um ICD S and um pacemakers. You have them just underneath the clavicle, I believe. Yeah. Yeah. So I saw in cardiology. So she's the girl to go speech if you got any cardiology questions. Um OK, so we'll move on done. Should we move on to the next bit? Yeah. Yeah, we'll move on. Ok. So going straight into it. So respiratory exam, it's the same kind of gest as the cardio exam. So your inspection at the end of the bed. Ok. So you still do all your stuff. Introduce yourself. Explain all of that general inspection, inspect the hands, OK? Have a feel of the hands, ok? Have a feel for the temperature. OK? You do a few other tests in the resp exam. So you would do things like checking for any tremors. Um And then I would also feel the pulse as well and check the respiratory rate. I vocalize this often with the examiner because you've only got so much time in the exam, work your way up. So you would then go on to checking the neck, you know, having a look in the face again, having a look at the chest and then this is where it has some similarities but has its differences. So, inspection, palpation, percussion auscultation. OK? But the aspects of that differ and we will, we will go through that as, as I'm showing you the examination when you're auscultating, you do certain things in the auscultation. So you'll be having a listen for the lung sounds, you'll be listening for when they're saying things like 99 and checking for fremitus. Um Yeah. And then I often do the lymph node exam uh when I'm examining the neck, but some people do it after you've done the whole kind of auscultation and all of that, there's no right or wrong answer, do it when you feel it, it's right. Um Always examine the back as well. So, I mean, you do in the front for the spirit exam, you're always doing the same on the back does mean it's nice and easy because it's literally reversed from a repeat. Um And then examining the legs. So checking for any signs of a DVT or any edema that you can see in the legs? Um ok, so Sarah is gonna be my trusted assistant again. Ok, so we'll just turn the the screen. Ok, so the same thing again. Ok, so hello, my name is Fitz. I'm one of the foundation. Two doctors. Could I just check your name and date of birth on the 5th 2000? Ok. It's nice to meet you. So, so and to do a respiratory exam, this is an examination of your lungs. What it will involve us. We have a look at the end of the bed. We have a post inspection of your hands, your face, your neck. I'll then be doing some more focused examinations such as having a feel of the lung, feel of the chest, having a a tap on the chest and also having a listen as well. I'll explain everything as I'm going along. Does that sound? Ok. Do you have any questions for me at all? Do you want a chaperone present during the exam? Just to make sure you're comfortable? Right? Thank you. Are you any pain or discomfort at all? Start? Ok. So I've already washed my hands, but I yeah. Um so I'll have a look at the end of the bed. Just see whether so looks well looks healthy, having a look around to see if there's any like oxygen cylinders around or if she's got any inhalers. Uh anything that gives me any indications of what, what might have brought him in and then I'll have a closer, closer look. So they always go from your hands. So, having a look at your nails, that's fine. That's fine. Ok. Just turn them over, that's fine. And I won't ever tell a patient whether I'm actually looking at her breathing or not. So I'll normally just having a feel of the pulse and then say to the examiner, I'd like to do this for the full 16 seconds and, you know, um, get the full weight, but then I'd also have a look at Sara, just see whether she's breathing it. And then I'd say to the examiner and then I'd also like to check her respirate as well at the same time whenever you tell a patient. Ok, I'm, now it's going to assess your breathing. They then start breathing really, really quickly. So I'll, I won't give the indication. I'll also just do it when I'm practicing. Ok. Uh So what I'm gonna ask you to do now is I'm just going to ask you to hold your hands out like this for me. Ok. And then what you can commonly do is if you get a piece of paper, you can pop it on the, on the hands and then it'll accentuate a fine tremor. So if you do want to see one that's more subtle, you might see the paper just flickering slightly and it can bring out those subtle tremors Ok. So I would often say to the examiner to see if there is a tremor, I'd probably like to put a piece of paper here and I might be able to see the tremor a bit more slightly. And that quite commonly you see in patients who use salbutamol or if they're on any beta two agonists. Ok. So then I'd like to just check for another chance if you just bring your hands back like this for me. OK? Some people teach like this, that's fine. You might feel them kind of pushing it. Ok? But, and tremor quite commonly, they'll hold it, ok? I'll hold it and then you'll start seeing it slightly. OK? And that you'll see in anything from uh any kind of encephalopathy. So if they've got any uremic encephalopathy, hepatic encephalopathy, CO2 retention, all of these kind of um conditions can bring out a, a fucking tremor. Um The other way is if you push back, you might feel them, push, pushing against you. OK? That's fine. So you've had a look, I don't believe there's anything else but no. Um OK. That's fine. So we'll just move up to having a look at the neck. So I still check J BP. OK? I then have a closer inspection of uh face. So having a look in the eyes going down the eyelids and looking up, that's fine. OK. I'll have a closer inspection in the mouth as much to, you know, and then I'd go on to folks examination on the chest. Ok. So I'll have a general inspection, make sure that there is there any scars preferably like her to lift her arms as well? Because she might have some scars on the thigh from like a chest drain insertion or something. Ok. Oh, sorry. Um OK. That's fine. So then I go on to uh having a feel of the chest. So we assess for lung expansion. So it's hard for me to just uh do the OK. So that's fine. So I'd wrap around and what you want to do is OK with your hands, you don't want to literally wrap around. Ok. Uh Because when you do that, it restricts the person's movement anyway. So it's very difficult to assess, assess someone's inspiratory effort that way. So instead what you should do is when you wrap around, you should kind of have your thumbs just sticking up. OK. So when someone takes a deep breath in, you're not, you're not constraining her. OK. So I would do that. OK. I would then have a excess apex. Don't I feel for the apex be just to make sure it's not displaced at all? One thing that I have forgot. OK. II normally do it on my palpation, but I would assess for things like trach or deviation and the high external distance. So tral deviation, what I would do is you get your two fingers. OK, next to your middle, just put it next to the cartilage area and then you just feel for where the should be, which is central. Then when you're assessing quite external distance, you have your sternal notch that sits just here. OK? C external distance should normally be about to use the three F finger finger lance or finger lumps. OK? Your cricoid is if you were to rub your finger along the the neck, OK? Your cricoid is the bit that just, just stick out that you can feel. Yeah. So that's where your c cartilage is. So the cell a distance is just in between that, that's fine. So we, we've assessed kind of the the neck in general, we've had a assessment for lung expansion. OK? So moving on to things like percussion. OK? So for I'm just thinking, I'll, I'll show you guys link for exam cos if you were on the neck, you might as well do it all at once. So your lymph nodes, OK? Go in a chain. So they come up here and then you've got some lymph nodes here at the front of the ears, at the back and then you work your way down. OK? It's the chain. So I often speak as I'm going through it. So just be on the submental lymph nodes here which sit just underneath, underneath the uh the chin. OK? Submandibular. It's just behind here. See your mandible. It's this bone here. It's a submandibular, just these lymph nodes. OK. Your carotid lymph nodes, if to see a pa glance, it's just a lymph nodes in it. And as I'm feeling, I use my II kind of uh some people will teach the spider technique where you feel l I don't like that because you can't actually feel a raised lymph node that way. So I will do the, the, the um more like a rubbing technique. So I'll kind of just go in like this and I can then properly assess it that it's almost like a massage. Um I'll feel any raised lymph nodes that, that are protruding or sticking out. OK. Last year, you preauricular, that's uh just in front of the air, your postauricular, which uh just behind the air there and then you have your cervial chain. OK. Your posterior cervical chain goes down this way. Your anterior cervical lymph nodes go down just to one. OK. So when I'm feeling in the posterior, it's fine to do it both sides. OK. So going all the way down and then you go into your supraclavicular. But when you're going up into your anterior cervical lymph nodes, I would only do one side. OK. The reason why is if you do both sides, you can stimulate both vagus nerves and then you can actually cause a physiological uh can cause a bradycardia because in effect, you're doing the man on both sides. So you don't want to do that because they might actually collapse or something. So the best thing to do is go from this side just basically the examiner. I'm just being in the right area nodes. Oh, actually you've got a raise paper. Yeah. You feeling well on yourself? Yeah, that's fine. Yeah. OK. And then I would just be on the other side. OK. OK. So submantle, submandibular carotid, preauricular postauricular cervical lymph nodes. And then you supraclavicular, quick question which uh lymph node commonly uh commonly do you find is raised when you have something like a lung cancer? It's very, it's very important that you assess this particular lymph node. Any ideas vert child's nose? Yeah. Really good. So your child's nose, OK. Sits in your left supraclavicular fossa, which is just it. OK. In lung cancer patients, you do find that it is commonly raised. OK. So that's why it's really important to work all your way down and feel that as well. OK. So that's fine. So we've, we've done all of the neck examination bit. So we'll go back onto the chest exam. OK. So having a feel, making sure there's good chest expansion. OK, checking the feet, then going on to percussion. So some people go through fingers, I II quite like three fingers because it means that you don't accidentally hit the patient if you go through. But I would just go from, you can see you're just aiming right for the center. OK. Some people go like this. Some people rest their hand and just do that. I prefer to do it like this because she's got clothes on. Uh, it's difficult to her. Um, but you're basically just are comparing as you go. So one side other and then you're basically working down and I would do it in your 33 zones of your lung. Ok. And compare it each time. So they don't want to see that. You do it on just one side and then you go in that way because if there's any differences, you might not be able to pick it up. So always compare to you going. OK. So you work down and then right underneath the axilla as well, you finish off and do one more. OK? That's fine. So we've done everything in terms of our patient concussions, then we go on to the consultation. So if you're having a listen first and the top part, OK, your three zones, OK. As you're going, having a listen here, I will then be checking for vocal pre. So the way you assess this is your OK, I'm gonna be having a listen and then I want you to say 99. OK. So, OK. OK. So every time I so sorry, I didn't that well, but every time my stethoscope or the bowel of my stethoscope touches your chest, I want you to say the word 99. OK? And then it's close to the patient and, and then working your way down. Ok. So we've done everything on the front of the lungs and you're basically eating everything on the back. So same thing you're checking for lung expansion, you percussion, you percussing, you're checking auscultation, having a listen. And then once you've done that, you've assessed everything in terms of the lungs and then move on to the, the legs. You can check sacral edema if you want. But ii normally just check pitting edema in the legs. So pitting edema, you're literally just pressing into the shin like this. OK? And then you're just seeing if there's any like indentation left in your finger. And then for a DVT, it's not from the front. I see a lot of people checking from the front for a DVT, they're not squeezing like this. So you're not squeezing from here, you're squeezing the calf itself. OK? So you're actually coming from the back. OK? And I would always just ask the patient, I'm just going to be squeezing your calf. Just let me know if there's any pain when I'm doing this because some patients will actually tell you, but they will feel a bit of discomfort if they do have a, you say, OK. And then that will include the example. You think there's a need that no, tell me if there is because if we will miss something. But the most important thing is if you get through most of your exam and you've assessed most of the components that you need to, then you've still done an exam that's assessed everything that we would expect you to. So, even in my exam, I had a cardio exam, I assessed most things, but I didn't assess temperature and I didn't offer BP. Ok. I wasn't in the world, the examiner was still happy with me and I still picked up, I still was going through the exam and picking up on things as long as you've got a good systematic approach, it's fine. And in fact, I'm sure you've all been on the wards and you've seen cardio exams that nowhere near include all of that. So yeah, we all know that this is, this is the skin. What happens in practice are two very different things, right? Any questions at all? No. OK. We'll do some more spot diagnoses for respiratory and then we're gonna get you all to pile up. Ok. And then we can all practice and we'll go round and basically see if there's any anything that you done differently or help at all. Um Does everyone have their stethoscope with them? I do have two spare. So if anyone does need one. OK. So we'll just go on to presentation again. Sorry. So we didn't mention. So I have a mnemonic for my respiratory exam that I like to use in, in uh the EK cardio always shadows respiratory. So if you're doing a respiratory exam, I would always offer to do a cardiovascular exam because they're almost one of the same. They do complement each other. And then I would also offer these things. So I like to call it spot X. So your sputum peak flow oxygen saps, temperature, X ray. OK. You wouldn't do this for all patients who come in with respiratory problem, but I offer it in the exam. So I will normally tack on at the end. Depending on the clinical scenario. I'd like to offer a sputum sample. I'd like to do a peak flow. I'd like to check oxygen sats temperature and I may consider a chest X ray. OK? So we've already done the demonstration that sy spot diagnoses. OK? So I've already shown you all. But this is a very good demonstration or video actually showing we, we won't go the video. It's fine, but it's a very good demonstration of what a fucking tremor should look like. So if you go online, you'll find a lot of different videos showing it one which is very commonly up on youtube doesn't actually show it the right way. And it's, it's someone demonstrating the fucking tremor, but it's not correct. So if you can find this one, it's a very good one and it's, it's definitely there. Um But you commonly just get that rhythmic movement. OK? Yeah. So that's just a general description. OK? This is a sign which I hope none of you ever see. OK. And that you definitely won't get it on your exam? Ok. This is something called, um, Trail Sign, I think just correct me in the audience with the other examiners. I, I'm pretty sure there's so many different signs with names of people. I'm pretty sure this one's called Trail Sign. But, but ii know the general principle, do you see that his trachea is slightly deviated to the side. Can you see that? So he's still got his Adam's Apple that's sticking out. But you can just see that that's where the tria is and it's kind of coming along like this, it's not vertical, it's coming off of the side. And what that does is when your trachea is pushing that way. OK? It pushes everything else with it and it's actually bringing out the, the sternocleidomastoid muscle, it's pushing out the head of it. So you get this protrusion of the muscle itself and that's something called trail sign. OK? But in your exam, that's why you're assessing the tria because if you're finding that it's not central. OK, then I'm sure all of you know what that could indicate. But I'll ask the audience, what's the one condition that we worry about if the trachea is deviated? Yeah. But what type of pneumothorax, tension, pneumothorax, good tension, pneumothorax is when the, the air in the lung is actually causing the, it's basically collapsing the lung itself. But it's also pushing everything to one side that is actually collapsing. It often can affect the heart can affect the other lung on the other side. So it's pushing everything and that's why your trachea gets moved and, and all. Ok. It's moving on. Any ideas what this is Horner syndrome really good. Uh So everyone always thinks which one is the dilated one, which one is the constricted one. So long as you can tell there is a difference between the two. This is a very obvious one, but you can see she's got ops. So this eyelid is coming down a bit. OK. The pupils much more constricted than compared to the other side. OK. And the way we can tell causes of a Horner syndrome is, is based on uh sweating and the patterns related. But that's when it becomes complicated in most cases because II work on ophthalmology. So we get in the uh an occasional Horner Syndrome for us, we basically do a full uh systemic work, work up. So we don't go down the route of asking. Uh Are you sweating just from your face? Are you sweating just from your body? Because no one knows we, we just literally do a CT do an MRI basically rule out anything that could be causing the problem because Horners Syndrome can be affected from a multitude of things and it normally is related to where it's affecting the pathway. So in your progress test, you'll probably get a question saying they have anhydrosis of the, the face, neck and torso and they'll be expecting you to know where is the lesion. But in practice, it doesn't quite work like that. And this is what I mean. So, um you have your four Ss, your forties, your four CS as I like to remember it. And it's related to where the, the problem is and it'll affect the, the, the sweating patterns for the anhydrosis. So for central lesions, they get um anhydrosis of the face, torso and neck. For the, the TS which are the preganglionic lesions, they get um anhydrosis of just the face. And then for the, the CS which are anything that you clotted up, it's your post ganglionic lesions, don't worry about that. Just recognize what a Horner syndrome looks like. Ok. Any ideas what this is? It's not very obvious. So, but describe the pattern to me and you wanna give it a go how would you describe this in an exam set? In an exam setting? Increased vascularization. Yes, very good. So yeah, I would say exactly like that. So in there's increased vascularization. So generally on the chats put ectasia. So this is ectasia but very, very subtle. And I would equally accept increased vascularization because you can see the development of small little blood vessels here and ectasia very commonly present. It's more like a spider web where it's like branching out. OK. So it's not entirely obvious from this picture, but that's why I used it quite well because if you don't quite know, describe what you're seeing and then it still is equally valid in an exam setting because they know you've recognized the pattern of something being abnormal. OK. So yeah, you got like the branching picture. Yeah, this is a very difficult one, but I'll give you the history and in fact, um I know one colleague from a different, different university in there that actually had a patient who presented exactly with this. OK. So they can bring these patients in any ideas. If I was to tell you this patient, um finds that they have a tightening of the skin, OK? They have swallowing problems. OK? We find it difficult to move and this has been kind of going on for a couple of years now. And when you look at the hands, I'll tell you the picture, they're very waxy, they're almost, they're blowing up like sausages. Really? OK. And they're quite tight, the skin's quite tight on them. I heard scleroderma in the background very good. So dactylitis, I would accept that as well. So dactylitis is inflammation of the actual um digits themselves, but you often get that with something else. So if you get that tightening of the skin in these patients, when you're looking and you're feeling, you'll find that the skin is very tight, they'll have, it'll feel quite waxy and it'll also have that appearance of looking quite waxy. So in this patient, they're very swollen and tight. OK? And the reason why I said about the, the swallowing problems, you can get something called crest syndrome. Ok. I'm sure some of you might have heard of it. Go away and, and uh, read about it as it is quite a, a common thing like test on progress tests and maybe even an exam setting. Ok. So this one is quite a difficult one. So I won't, uh I won't put you guys on the spot. So this is something called microstomia. OK. So long as you know what looks normal and what doesn't look normal. So in her case, her skin is quite tight. So the lips aren't opening that wide. So she's got quite a narrow opening, mouth opening. OK? And microsomia. So this is another presentation or a sign that you can get in systemic sclerosis. OK? Any ideas what this is pus excavation really good. So you've got a depression in the actual thoracic cavity themselves. These patients are commonly born with this. Um And it's very commonly related to other connective tissue disorders like your ed uh Marfan syndrome um all sorts OK. And this is the, the sister of pus exc excavator. Many ideas. Anyone if you've got excavatum, carinatum really good. So, carinatum, actually, it comes from Latin, I think, which is like beak or something. And the way I remember that is because while it, it looks like something is sticking out almost like a beak. Um So Excavatum is the depression in the face cavity, carinatum is the kind of protrusion in the in the facet cavity. OK. To next um I won't, I won't get you to watch the video. I'm trying to, yeah, that's fine. If you want to have a look at that video, it's quite useful for showing a specific sign as well. Um This isn't something which I'm not going to ask you guys what it is because it could be anything. OK? But if I was to tell you this patient, um, has a lung cancer diagnosis, OK? And you just see this very specific spot just where you can hear the uh where they say they may have had the lung cancer or had the operation or something. This is what a radiotherapy tattoo looks like. Ok. So when they're marking someone for radiotherapy, they'll put this specific kind of indentation where they're going to do it. Ok? Um So if you see something like this, it could just be a skin blemish, but also it can indicate that they might have had some radiotherapy. OK. But it is quite a subtle thing to pick up so very difficult to see sometimes. OK. What do you think this looks like? It's probably not the, it is related to this talk, but kyphosis really good. So they've got like that hunched look to it. Um It's the one which like the gamers get if they spend too long on their computers. Yeah. OK. So kyphosis. This is the other one. So, lordosis, they're sticking, I like to think of this as like the Lord one because they're like, you know, they're, they're too proud for themselves, you know. Um So lordosis. Yeah. So it's uh scoliosis. Mm. I'd ask all of you to go away and listen to all these sounds. It's really good to know what each sound is like. Knowing the difference between what fine crackles are ch crackles and all the different sounds that go alongside them for spot diagnoses patients that I think they could bring in on the day. Your COPD patients, patients who have asthma where they brought in their inhalers and left them at one side. They're not going to bring in someone with an asthma attack, ok? Um patients with lung cancers um with specific features relating to them and patients who have conditions different to what you'd standardly expect in respiratory, but have signs you can pick up in the respiratory exam like a patient who might have a scoliosis where when you're having a look at the back, you know, you may actually see that it's slightly verged to one side and that can easily explain someone having a type two respiratory failure where they're not ventilating their lungs as well. So it's just as good a sign to pick up, you know, even the respiratory exam, ok, right onto the, onto the main bit. So if everyone could power up, ok? And then what we'll do is we'll practice the cardio exam first. Ok. We'll give you about 20 minutes. So one of you can do it and then the other can swap, see if you can time yourselves with it. So another thing people like to ask is, should I talk through what I'm looking for or not? What I want you guys to just get good at is knowing the steps and being very slick before you start saying what you're looking for. Cos I've already tested you guys on spot diagnoses. Ok? So I know what you're wanting to look for. So now I just want to see, can you just get the raw element of how to do the exam and being thorough and time yourselves as possible. So give yourself the seven minutes and say, can I do a respiratory exam or a cardio exam really quickly and don't beat yourself up if you don't forget like temperature or something? I'm not and I just want to make sure do you guys have the general principles down pat? Ok. Yeah, for those online. Um Thank you for coming. You guys are more than welcome to practice on your housemate right now, but we're gonna enter here with the online spot diagnosis bit. Um Yeah, thanks for coming. We'll send the feedback on the chart and yeah, anyone in Cardiff Rosa should be there and then banker I sort it out. No, that's brilliant. Thank you very much, Miss Smith. Thanks for coming. Thanks everyone. Thanks for coming. Um, yeah, the, um, fee feedback for in person is on the last slide. Oh, ok. Yeah, that's fine. I'll, I'll get, I can put it in now but it's only for people in person. Yeah. No, that's fine. That's fine. All right. Thank you very much, Roma there. Well, you guys can fill that out at the end if you want. It's fine. Brilliant. All right, we'll all power up now and we'll get, we'll get going and just so you know who the, who the, er, staff are, so we'll introduce yourself. So you already know me.