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So brilliant. We are live now. So, hello, ef hello everyone and uh thank you very much for your patience and thank you for joining today's session. My name's Lock. I'm one of the moderators here from um BDA British er International Doctors Association Student White. And um, yeah, today we'll have Doctor Sam here and um we are going to be talking about um, dizziness, history taking as well as some osk tips. So, um without further ado, I'm gonna hand it over to doctor was um, the, the session will also be slightly interactive. So, um if people can, can just comment their, what their thoughts are in the chat and I will read it out. That'll be very great as well. Um Without further ado over to you, Doctor Wester. Hi there guys. So my name is Doctor WSA. I'm, I'm af two doctor. I'm currently in uh the emergency department. Um, today I've done a presentation about dizziness. Um I was asked to do something that was helpful for osk and history taking and uh when I was in fifth year, my fi er final year of med school, um we got dizziness as a um ay station and for some reason it threw everyone because they were like, oh, this is, you know, different or didn't know what to ask or didn't know what to do in this situation. Uh, so I decided to make a, a little, um, case based discussion, um, about it. Um, before we start, if people in the comments could say like, what year of med school they're in or what, what stage they are during their training, they're just giving me an idea of um what we're w what level we're dealing with at the moment and then I can get stuck into the presentation. So if whoever wants to just like, tell me what the. Ok, nice. Third years, fourth years, nurse practitioner, primary care. Ok. Good. Fine. I will not delay then and I'll get started. Ok, please uh let me know if anything goes wrong technically, during the presentation. Yeah. Ok. So dizziness, a case based discussion. So this is a based on a patient that I've seen. Um his na, his name is Mister X. Uh He's a 73 year old and he presented with about three days history of dizziness uh and headache. So the history is a presenting complaint goes as follows about 33 days ago. Uh He, no, he noticed it suddenly come on after he was trying to get up from the sofa after he was sitting there for a few hours. Um He mentions that it's a unsteady or imbalanced feeling and it's been persistent the whole day. Um, it's not constant in its intensity. Sometimes it's more and sometimes it's less. Uh, he has been feeling nauseated and sick, but at this point, no vomiting, uh, has occurred. Um, the headache he developed later on after the dizziness came on, um, moderate around the forehead, um, and rubs bilaterally around there. Ok. In terms of the dizziness itself, it was exacerbated by him, moving his head suddenly. Uh The important negatives is that he wasn't feeling faint, he wasn't getting any spinning sensation, no ear pains, uh no tinnitus and he didn't have any temperatures. Uh He also didn't have any vomiting, facial drooping, numbness, weakness, vision changes or weight loss. Uh And he's never had an episode previously like this before. Uh Normally he just takes uh paracetamol and Ibuprofen uh over the counter for, for this, but it's not been helping. Um He has preexisting hearing difficulties which is a conductive hearing loss. Um one ear, totally deaf and the other ear. Uh he uses a hearing aid. OK. So at this point, I'd like to throw it back to the audience. Um And this is quite a good exercise for, you know, anyone who's um a medical student or who is gen in general is thinking in terms of differentials. So, based on the history that I've told you at this stage, what differentials could you give me? I'll uh ask Lock to shout shout me the um, what's in the comment box? Yeah, I will do, I'll be monitoring your chat. So feel free to type down your thoughts in the chat. We've got BPPV. OK. Anything else just throw out as many as you can, even if it's likely unlikely, you know, query B PPP. Slaps vertical. Yeah, let me see. Vertical BPPV. That seems to be the trend at the moment. OK. So that's interesting. Interesting. Um I'll wait one more. I'll, I'll wait for one more person to put something different to be BPV. Yeah. Something different. Postural hypertension. Ok. Good. Um Sandesh asked any history of recent viral illness. Um, so no, no history of, of recent viral illness. He ca he can't, he can't recall. Ok, I'll with that, I'll move on to the next slide. Ok. So, um, this is his past medical history. He's got hypertension and he's got type two diabetes, normally manage the type two diabetes with just Metformin. And, uh, the rest are kind of cardiovascular drugs. So, antihypertensives, statins, uh, and omeprazole, uh, that he takes, none of these were take were started, um, recently. Uh, so all of them he's been taking for some time already. Um, doesn't have any allergies and he doesn't have any family history of dizziness in the family or anything related to that. Ok. Uh, in terms of his, uh, social history, uh, he's an exsmoker. Uh, he about 10 a day for 35 years. And he's quit, uh, 10 years ago and, um, he drinks around 4 to 5 units a week. He's very occasional drinker. Um, and he lives in a bungalow with his wife and he's independently mobile. Normally. No walking aids and he can complete all of his ADLs. Ok. So when we went to examine this gentleman, he was very unsteady on the feet. When I first called him, he was grabbing onto the wall for balance. Um He was at rest, so he wasn't um you know, in a, in acute severe pain. Uh and his observations all were, you know, within normal ranges were stable. Um With this, you, you want to do an ear exam. So, uh we looked at the ear, um I've given you like an image of what it would look like. Uh You, we found no uh discharge, no inflammation, um tympanic membrane intact, uh and ossicles seen and there weren't any vesicles or anything like this in the ear canal, either he didn't have any uh neuro neurological signs. So his cranial nerves were intact. Um And obviously, we couldn't properly test his hearing cos he already had an existing uh impairment. Uh Yeah, and again, upper and lower limbs equal in, in power and sensation. Um and uh he's didn't have any acute confusion, didn't have any slurring to his speech or any changes uh related to that. Now, if someone can tell me, uh this is just like a basic question. Uh What is Romberg's test? Someone can put in the comments. Let me monitoring the chart. Now, Katie said, can't stand stable with eyes closed. Yes. So this is the test where you make them uh close their eyes. You put two hands uh on either side to see whether they're swaying from side to side. And uh you just ask them to close their eyes and when they close their eyes, they don't have their vision to kind of as a stabilizing factor in their balance. So you can see them sway from side to side, you can see them totally lose balance. Um This is, is not strictly just to see whether they don't have balance. As I said, this gentleman who was grabbing the wall for balance. So that told me that he's off balance, but this is kind of a test that will help gauge in your mind. How uh you know, dizzy are they, how significant is this in? Some people? They can keep complete balance. You give them a, a little push and they kind of regain themselves and some people, it's absolutely like they fall to the side immediately. OK. So when I asked you about differentials, some of you mentioned BPPV, which is up there, uh BPPV is a good uh thing to, to um differential to go with first because it is the most common cause of uh dizziness um in uh Precare, I think I I'm not too sure about the secondary care. Um These are the other differentials that you should keep in mind and that they might be less common. But it's important to rule these out, especially in older gentleman who has a smoking history and hypertensive as well. So the main one, the kind of red flag one that we want to um eliminate from our differentials is uh a cerebrovascular event. Um You have two types of dizziness, you have peripheral and you've got central. So the peripheral is your inner ear, which is your organ, er, that helps you with your orientation and space and your balance. Um And then you have your central, which is your brain stem, um, or your cerebellum, er, and they are important for interpreting the signals that come from the inner ear. Um, some of you also mentioned postural hypertension, which was uh a, a good thing to think about as well. So you definitely want a line in standing BP on this gentleman because it first came on when he got up off of the sofa. But um what makes postural hypertension a bit less likely is that it's been persistent, it's no matter how, you know, um, long uh passes, you can never get back down to a baseline of like no dizziness. Um, in addition, um he, um it's a, a sudden onset and he's not been started on any, any new medications. So it would be a bit strange that it's just these three days uh of dizziness, other things that can present as this dizziness type symptom include uh migraines, um anxiety. So, especially if someone's hyperventilating a lot and they're anxious about something that can cause a bit of like a room spinning, dizziness, sensation and of course, drugs and alcohol, you know, whether they're pharmacological drugs, illicit drugs. Um and they're always important to ask about specifically uh in your history. Um The other one is like vasovagal episodes which is slightly related to the orthostatic or postural uh, hypertension. Um, but again, these would be episodic, you'd get this isolated episode, then it would go away rather than the constant, er, persistent dizziness and then, uh, as well, um, is vestibular neuritis or labyrinthitis. Um, so I'll, I'll actually throw this one back to the crowd and see if you guys are aware of anything related to vestibular neuritis or labyrinthitis or, or, or what it is. Let me monitor a chat. Yes. Sandesh said VN does not affect hearing. Yes, that's correct. So, vestibular neuritis or labyrinthitis is an infection of, uh, the nerve, um, that supplies either your, uh, hearing or your balance or, um, so your, your, the, the nerves that transmit the signal from your inner ear, er, centrally to the brain, uh, similar if you think about a Bell's, er, palsy. So Bell's palsy, you get this, um, drooping, er, of the face and the facial, uh, asymmetry secondary to a nerve, um, infection, uh, and it can often be a mimic to a stroke sometimes, uh, in the same way, vestibular neuritis is very similar. It just affects a slightly different, er, nerve, er, and you get, uh, these, um, u unilateral, er, symptoms. Ok. Fine. So we'll go, we'll go on to talk about those, uh, a bit more. Um, I've also included, uh, like a textbook, er, list of all the different, er, causes of, um, vertigo. Some of them, we won't actually go into uh, in depth, er, for this talk. Um, uh, but as you can see here, BPPV, vestibular neuritis, menia, they're all in like the top um, peripheral causes and um, the central causes include the, this vestibular migraine that you can get a brainstem ischemia or cerebellar uh ischemia or infarction or hemorrhage. Ok. And then there's the bit more rare ones malformation or multiple sclerosis can also present like this but with multiple sclerosis, what other symptoms, uh, would you expect to see? You'd, you'd want some extra symptoms as well? Can anyone tell me? Let's see. Optic neuritis, yes. So you'd want some optic neuritis. You'd want, you'd want um, symptoms that um, occur like over time. Uh, not like an acute episode like this. Multiple sclerosis. Wouldn't be the first thing that pops to your mind. Ok. So what other examinations could we do? Um, now in the age of the CT scanner where CT S are quite er abundant. Now, uh, often times uh you, these are um you know, CVA is excluded with a quick um ct of the head. Um However, I do think it's important um to learn some of the more the examinations that can differentiate between the peripheral or central cause because not every single person you want to uh give a head ct. Um And in addition, um when you learn these examinations, II find myself, it gives you a better understanding of the causes uh and the actual, you know, um a of the conditions themselves. So there's this thing called the peripheral hints exam. This is specific for vestibular neuritis. So for all, for vestibular neuritis to be the most likely diagnosis, all three have to be present. You have head impulse nystagmus and test of skew and I'll go um a bit more in detail about these. So the head and pulse test is uh basically you ask uh your patient to fixate their eyes on a particular um place that could be the bridge of your nose that could be like a marker or something like this. And then you hold their head and you relax the neck muscles and you move them side to side and as they're moving side to side, they should be looking directly at the point of focus. OK? And then you do a few more kind of jerking movements. So a bit more um fast movements and you move it like this uh in a person who doesn't have um a positive head and pulse test, their eyes will still remain fixated on, um you know, the area of focus um in someone with vestibular neuritis where it's a nerve conduction uh problem, basically, um you'll get this um delay where their head will move and their eyes will move alongside it and then a quick sad they call it and it kind of, it meets back at the point of focus. Um There's a small delay, slightly counterintuitively for this test if it's positive and they have that Sicard, it's actually reassuring cos it means they don't have a stroke or a hem hemorrhage or something along those lines. It's more of like a vestibular neuritis, which is more benign of a condition. Um So if you get a positive on this er in someone who's got persistent uh dizziness, that's like a reassuring er, feature. So then it comes to the uh nystagmus, you have different types of nystagmus. I won't go into the full depth. You could do a whole talk about uh nystagmus. Um But basically you're, you're kind of looking at the er, eye movements and you're mo er and you're moving horizontally and vertically vertically um in the BPPV, you're more likely to see some of these er horizontal um er and rotary er nystagmus. But if it's a central cause you'll see only um one so vertical, you'll see it just by itself or horizontal, you'll see it just by itself. Um And that can be a sign uh of, you know, um as I mentioned, it's au unidirectional. So it goes to one side if it's bidirectional. So as you look to the left and as you look to the right, uh then that's more of like a central cause rather than a peripheral. OK. Next one is this um is a test of skew. So this is a, a test where you can use your hand and you cover uh the person's eye and then you move from one side to the other as you move to, to one side to the other. If you get a vertical um, er, movement of their eyes, er, either upwards or downwards, er, as you move from side to side, that is a positive er, test and that suggests something central is going on. Ok. So this is just a summation of like the hints exam. Um Yeah. All right. So as I mentioned before, the investigations that we're gonna do, we're just gonna run routine uh, bloods, we can do Weber and rene for hearing an audiogram for hearing as well. If there is any neurology at all, you're going to do a CT head in this case. Um There is also one thing that actually I forgot to include in my um, examinations, er, section um to do with the cerebellum. Can anyone tell me what, what, what signs the, the acronym? Let's see if anyone types anything into the chat? Haven't got anything yet. So they are the uh Danish signs. So can anyone tell me, you know what d stands for, for example? So, yeah, KT just said the Danish. Yes. So you're looking for Dys Diy Arthro Kinesia Ataxia Nystagmus, um intentional uh tremor um speech. And then anyone tell me the, the h Yeah, we are, we have a few. Um I think the audience are just catching up right now. So we have a few this, they're called kinesio right now. Uh But yeah, um Does anyone know what H stands for? Like he says, hypotonia? Yes, good. Ok, fine. So next, this gentleman, uh he, he, he did have a uh CT head um due to his age and his risk factors, um he did have a CT head. Uh and, and due to the fact that it was, had lasted around three days uh as well, um There was no, no intracranial pathology on the CT head. Uh So it was diagnosed as a vestibular neuritis or labyrinthitis. So, as I mentioned before, this can mimic uh a CVA similar to Bell's palsy. And actually, it's the second most common cause of vertigo. Um Normally how this works is it's about a 3 to 5 day acute phase where they get really intense symptoms and then they slowly recover uh their balance and dizziness. Uh Over three weeks, you can get quite um severe nausea and vomiting. Uh And normally they have this gait impairment where they can't, they find it very difficult to walk. And I think it was Sundeep who mentioned about, er, have they had any viruses or anything like this recently? So usually it is a post viral, er, inflammatory er disorder, um, in this gentleman that wasn't in his, er, history. Um, but, er, you know, it, it, it, it's an important question to ask. Ok. So any ear infections in general is a risk factor for, um, this kind of, um, um, syndrome. Um, in pure vestibular neuritis, you don't get any hearing loss. Obviously, in this gentleman, it's a bit more difficult to assess whether they had hearing loss or not. Um, and, um, if you do get hearing loss, it's called labyrinthitis. Cos it's the whole, um, system that's being affected. Ok. So how do you manage it? Um, you can get vestibular suppressants so they can be antihistamines. Um, so often times in the ed, what, um, oftentimes the consultants, uh, quite like to give is an im, uh intramuscular shot of uh promethazine. Uh, and actually I've seen it be quite successful where when you give, uh AAA good dose of it, it calms the symptoms down and they're able to walk again. Um, cyclizine works as well. Um, and then you give uh antiemetics as well for, uh, you know, uh nausea or vomiting and really this is the kind of, um, uh, kind of tenants of the, uh, treatment, which is just symptom control until your uh body gets over the uh infection that's caused these symptoms. Um If it's the, in some people, even though they treat the symptoms, this condition does persist for quite a long time. And even after they've been investigated for all the causes of dizziness, it still um is uh vestibular neuritis, which is the most likely cause or recovery from that vestibular neuritis infection. So, with these people, they ca they have this uh physiotherapy uh rehabilitation, so they do movements of the head and things like this. Um and usually that tends to help with um their symptoms in the long run. So these are just some of the tests that could, you, you could do um the dix Hallpike maneuver is specific to BPPV. Er And then can anyone tell me about the maneuver that um it, it, it treats the symptoms, it's not just diagnostic, it treats the symptoms of er BPPV. Anyone name that maneuver for me? Um We actually have a question. Would you like to take it now or like? Yeah, sure, sure. So uh we have a question about for blood. Do you need C RP slash E SR for VN? So it's unlikely that um you will get any inflamma inflammatory markers with a viral uh kind of localized infection like this. Um You can add uh C RP um or E SR but it, it, it's um it's unlikely to be uh something that is, would differentiate you between your peripheral versus central um er kind of determination that you have to make brilliant. And um yeah, so if he says Epley, yes, Epley maneuver. So, um I did a GP placement, uh my last rotation and um uh actually, it was the first time that I could try and do this um Epley maneuver for a patient that was coming in with the dizziness and um the first one didn't work, but then the second one I had it was very, very like dramatic the change they went from, you know, grabbing onto the walls u using a stick and everything like this. And um the maneuver really had like a significant effect on them and they were able to like mobilize and it kind of got rid of the dizziness for, you know, that period of time, it's quite ii if you do end up er in your practice, er getting the time or opportunity to try it, then you can watch some of the videos online. They're quite informative, give you a step by step um process of how to do it. Um The, the main mechanism of this er is your inner ear canal. Er, it has um endolymph inside it, which have small crystals, those crystals hit against the walls of the um you know, inner ear organ. Um and that is what gives you your um you know, your orientation, your balance in BPPV. Er these er, you know, it gets scattered basically these crystals. Um, and the, er, Epley maneuver and the dix Hallpike maneuver is all based around using gravity to manipulate this fluid into a position where either it triggers your symptoms or it, you know, er, gets rid of your symptoms. Ok. Fine. So, um, I know I've had one question and I don't know what time I'm on now. Um, about halfway through the, um, er, time. Um, does anyone have any questions about the presentation I've given or do you want kind of osteo actually? Yeah. Um, the question goes, do you need to make a routine referral to audiologists or any other specialists for every case of? No. So, n normally, um, so the, there's, there's differences in what setting you're in, um, if you're in a, a GP setting, um, really it depends on the severity of the symptoms, er, if you're getting someone who's got quite severe intense symptoms and it's not responding to say, for example, you see them initially in the GP clinic, you give them some, maybe promethazine or you give them some, um, a cyclizine for the nausea. Um, and it's still not got rid of the dizziness and it, and, you know, you've taken a history, you've taken an examination, um, and nothing suggests kind of central causes, then yes, you can refer on to the ENT, um, and normally the ENT, uh, they have kind of specialist physiotherapist whose whole specialist specialism is to do these, um, Epley maneuvers and, you know, um, to kind of, er, do that vestibular rehabilitation and they can get investigated further. But, um, um, ii wouldn't say the first time they present to you, you would refer onwards to, um, like a ent specialist. You try and give them some basic symptom control medications. If it's still persisting, if it's persisting more than, like, you know, two weeks or something significant and it's affecting their quality of life, then yeah, you would refer onwards for, for further assessment in the emergency department where I'm at. Um, we don't, we normally refer uh on, we, we tell them to see their gene if the problems are uh persisting. Um So, yeah, hope that answers your question. We have another question coming in. Um Is there any D VLA requirements when someone presents with vertical symptoms? So I'm not quite sure about that one actually. Um, I'd, I'd have, I, I'd say that the, what, what I would do to look that up, but I'd look at the nice guidelines. So, um, the nice have uh guidelines for vertigo uh in general. Um And from my understanding, just normal BPPV, people don't get referred to the uh D VLA. Um, but you'd have to see how significant the impairment was. Obviously, if it's a central cause of the uh dizziness, then yes, you a after a stroke, I think it's roughly, you know, um, three months at least you have to wait before you can be assessed again for fitness to drive. Uh, we have another question in a GP. You only have 10 minutes. Is there a quick way to do cranial nerves exam safely? Ok. So, um, the cranial nerves, uh, actually I think people tend to, um, overcomplicate it and think it's this very, very long and tiring examination at the end of the day. Um, yes, you have 10 minutes to see each patient. Um And obviously this is for like uh qualified GPS, people who are um you, you know, um F two S like me or um GP trainees, for example, they have a bit of, of a longer time to assess their patients. However, with that said, um some of your patients are gonna be just a simple ear infection. Some of them are gonna be uh kind of a simple cough and cold and that will take you, you know, less than five minutes to get through. You can take the, the hit on the time to properly assess your patient neurologically cos I think it would be quite important to uh at the primary care level to make sure that your patient um doesn't have any signs of stroke, for example. So uh you people don't normally test the olfactory. So the nose one, but ee everything from, you know, two till um 12, uh it wouldn't take you longer than, you know, six or seven minutes to uh, properly assess. Um, and I think it's ok for you to slightly run over your appointment time. Um If you think that there's a suspicion of, um, you know, uh, central like neurology or anything like this brilliant at the moment. I don't see any further questions. Ok. Please feel free to ask more questions. Um Oh, so this is like my last slide. Basically, this is the more kind of rare, um, causes of dizziness. So you have Ramsay Hunt syndrome. Um This is usually caused from a herpes zoster virus um, infection. Um And in the ear exam, you'll see these kind of herpes like um, vesicles in the inner ear canal. Um And it can, it'll give you the facial nerve palsy, give you some dizziness and um, auditory symptoms as well. Ok. And then this is, uh, at the bottom left is the Arnold Chiari mal malformation. Um You have these large ventricles, they push on the cerebellum, uh, and you get this dizziness from it. Um And then in men years you get this, um, swelling uh of the, um, endolymph in the inner ear canal. Um, sorry, in the, um, labyrinth um, uh structure. Um, and it causes um, distorted inflammation, uh that to travel to the brain. Ok. All right. So, with that done and dusted, I thought I'd dedicate a bit of time to talking about the sy actually, um I'm gonna come off of this one and stop sharing, uh we have one more question just that has just come in. Um Is there any red flags uh questions that we should ask for dizziness? So any red flags um So a re red flags would be like fast symptoms. So, facial drooping ataxia, uh sorry, uh facial um facial drooping, uh asymmetry, uh speech, you know, anything that suggests stroke from the exam uh or the history, then that would be a flag. So for example, also your demographic of your patient. So if he's like a, you know, 50 day, 50 a day smoker, he's high BP, he's got type two diabetes, he's got all the risk factors. Then those shout out to you more. Ok. This gentleman is more at risk. So we have to be safer, uh, and scan his head, for example, um, usually the kind of more severe like, uh, from my reading, of course, er, like this more severe um, nausea and vomiting symptoms in, um, this type of presentation is actually associated with the peripheral course. So it might be that they look a lot worse, they're vomiting and nauseous in front of you, but that is more associated with peripheral um, vertigo, but it's, it doesn't exclude either. So, um, so yeah, hopefully that helps with your, uh, question. So to come to osk, um, a lot of people get worried about the OSK, um, and they get concerned about, you know, um, them having to know every bit of information, uh, answering all the questions correctly. Um, having, you know, uh, you know, explored every part of the history that, that there's there to explore. And actually sometimes I think the anxiety, um, around, um, ay can be, um reduced. Um, if you have a good understanding of what they're looking for you, uh, when you do the osk. So the ay, um, there's two aspects to the marking. There is the tick box exercise, which is, you know, how many pillows did they sleep with at night? How many cigarettes did they smoke? You know, did you ask, um, you know, the sight origin onset, all of these Socrates of the pain, et cetera, et cetera, et cetera. And they're important for you to ask. But the other one that gets, uh, often overlooked is there's a global marking. Um, and depending on the medical school that you go to, er, sometimes that global marking is quite a significant, uh percentage of the total mark. Um, so what constitutes the global marking? That is basically the vibe, that's the best way I can put it to you. The vibe that you give to your assessor or your examiner when, because it's, it's, it's basically at the end of the exam they get a, you know, what do you score the student globally? 0 to 9 or, you know, 0 to 12 or something along those lines. And they, it's entirely subjective, they can give whatever mark they like in that range. Um And it's not necessarily, they have to justify it in this way or that way. It's, it's their own opinion as a clinician. Um So you should look at the osk as not you communicating necessarily with the actor in front of you, but you are communicating to the assessor that's sat on the side and observing you in the same way in a driving test, you know, they always make a point to exaggerate, looking at your mirrors. So you look at this mirror, you look at this mirror and then you check your blind spots and you make a big show to the er, examiner in front of you that you're doing all the things that you need to be doing, you need to show to the er assessor er, that you are a competent, safe and professional er doctor or practitioner. OK. Um So what can make you more confident in terms of approaching um history taking, for example, uh with any uh patient, there's a little game that me and my medical student colleagues we used to play, which is basically we call it like the, the differential game. So when you are with your colleagues or your, you know, your friends or maybe they're your flatmates, you should be able to shout out any presenting complaint. So by presenting complaint, I mean, cough, shortness of breath, chest pain, headache, dizziness as we talked about um you know, leg swelling, leg pain loss of vision, you know, any of these um just a one sentence presentation, no other details. You don't need to know any other historical details from just that one word. Cough already. You should be able to give me immediately within 10 seconds, six or seven different things that could give you a cough. This is before you've even taken a history. Now, often times in the ay you see people and they're writing down on their sheet of paper, you know, outside the exam and some people are writing things like, oh ask about smoking or, you know, uh ask family history, ask this, you know, those are the simple things that you should be asking in any case. OK. The clever students, the ones who do very well on the ay what they're writing down is uh differentials. And just so you have an idea of how uh the exam marking works. You will get points for questions that exclude or include a particular differential. OK. So, you know, if you're asking about a uh cough and you're asking about uh whether it's productive or nonproductive or whether you're asking about chest pain, uh and you're asking which, where's the site of it? And you know, whether there's radiation, all of these are differentiating questions. So to save yourself time um in a already kind of time scarce setting, make sure you don't ask any stupid questions that don't differentiate between your differentials. Um This shows the examiner, when you're asking your questions, you're asking with a purpose and like I said about the checking your mirrors and things like this, the doctor or practitioner who's gonna be assessing you, they will be able to tell what you're getting at in terms of your differentials based on your questions. So when you start narrowing your questions down further and further based on the patient's responses, they, they are able to see, ok, he's thinking about a cardiac um uh cause of chest pain. Oh no, he's thinking about pe as a cause of chest pain and you can narrow it down further and further. OK. So, differentials are very important and some presentations have like loads of differentials, but it's still important that you don't order them. And um if I can make one recommendation um for like a, a book or like something for you guys to read, if you want to get very good at this differentials game, um It's called Focused History Taking for the Osc focused History. Taking for the OSK. It's written by an, a author called um M mccollum. OK. And it, it's published by um masters who's the publisher, I swear by this book. Very, you know, uh a lot because this is the book that helped me in my third year, er Acies and I, it still helped me in my fifth year, er Acies. Um Basically the structure of the book is, it's just a whole book of presenting complaints with the different conditions and it tells you under each condition, what questions you should ask to differentiate between one of the other and what's how the symptom changes, depending on the condition. Very, very good and well written book. And if you learn memorize that book, basically, you will be like a master at any Akie station that they throw at you. Ok. OK. So then it comes uh then the other advice that I would give to you is regarding like the global marking uh side of things. So how you might be asking, how do I show that I'm uh competent, that I'm safe, that I'm et cetera. There's a few different ways you can show this. So firstly, in your manner, the main thing is is that you want to appear uh calm and collected. There's some people who make this mistake in the sy they think like, oh my God, I ha I can't um ask everything I want to ask in this short amount of time. I'm just gonna machine gun questions, ask a question, ask a question and then like keep on loading the patient over and over again with many, many multiple questions hoping that they will tick all the boxes of the um examiners mark sheets. That's not a good approach, in my opinion, because you are gonna lose out on your global marking side of things that appears to an examiner. Um like you are aimless and you're kind of panicked and you're desperate. You know, you don't want to seem like that you want to seem calm. So when you're talking, talk slowly, talk in a calm collected way, let the patient finish what they have to say. Of, of course, if they're, you know, talking too much or not giving you information, you can guide them, you know, to a different line of questioning. But, um, have pause and I'll show you now, like when I talk with pauses, there's more emphasis. It seems more, you know, confident, more calm, more direct, you seem um a lot more collected. Even if you have to take a moment to think about what the patient has said, then sometimes you can take a sip of water, the water on the table is there for a reason for you to like keep calm and collected. You don't have to fill every single space of silence with, you know, conversation. OK. Fine. So that's um regarding like your um you know, how you you speak and how you come off. The other one is a technique that I find very helpful in the osk, which is summarizing. OK. After you've taken a history from the patient, you can say to them. All right. So, you know, correct me if I'm wrong. But this is what has brought you in. You've come in on xy number of days, you've been having this symptom, it affects you like this, it radiates like this and the, and you just summarize everything they've told you in that time period, in a sweet but concise bit of information. So e even if you know all of this stuff already, the reason I'm telling you to summarize is 33 fold. Number one, it collects your own thoughts about the issue. So as you're talking, sometimes the diagnosis or the differentials might pop out to you in your mind saying, um, you know, oh it y you forgot to ask about this and you, you will ask that if you, if you've forgotten. The second reason is because sometimes, you know, this is like a subjective thing, but sometimes the actors, God bless them. They have pity on your soul as a medical student, they have sympathy towards you. OK? They will see that you've made an effort to gather as much information as you, you could. But maybe you didn't ask a direct enough question on one of the times or they, you didn't say something specific that triggers the actor to respond to you and they will give you that bit of information for free because you've summarized and you've shown look, I've gathered all the bits of information and you know, basically they're, they're helping you out cos they can see that you've made an effort. OK? And then the final one, which is probably the most important one is your examiners and your assessors. They are forgetful people like all of us. Are sometimes in, you know, an osk circuit, they've seen many students and it's very easy for them to zone out slightly. Um, and they might start thinking about something different. They might not have not had lunch that day. They might have, you know, thinking about, have they look at the house or something like this. When you say those words, I am gonna summarize or like just to summarize, they suddenly switch on again and then they start ticking on the ipad or the piece of paper. All the different things that you're currently summarizing. You might have said it already or you might have got that information already, but that gives them the attention to kind of um realize, oh yes, he did actually say that, ok, tick tick tick and this is a safeguarding mechanism for that tick boxing exercise. OK. So those are my general tips for uh being good uh at the ay um Some of the other things that I would mention is just don't forget the simple things. So make sure you get like a good idea of like their, you know, morbidity status, their smoking history, alcohol history, family history. All of these are just little points that people sometimes miss often times in a Ayer scenarios and stations. They have a point for if you give them a patient information leaflet at the end like, oh I think you have this condition. Here's a leaflet about the information and you know, you just give it them. So don't, don't get lost in the, don't focus too much on these small details that, that ultimately, you know, you, you could discard them and still pass a station, but at the same time, he's gonna pass upon free marks, you know, at the end of the day. Ok. Um fine. So if anyone has any questions specifically about um Aussies and um you know, advice regarding it or, you know, you, you want some kind of like, uh tips on a specific aspect of the osk, you know, please let me know I'll be happy to answer. Yeah, if you do have any questions, please feel free to type it in the chart. Um, I believe we are towards the, at the end of our session. So I will send out a feedback form and if uh, if our audience can fill it out, you'll, you'll then get a, um, attendance of, um, attending a certificate of attendance, my apologies. Uh Yes, we do have questions. What's the name of the book that you mentioned? So, it's called Focused History Taking for The Aussies by, er, an author. His name is Mick Colum Mick column. Uh, and it's by Master Pass. It's, it's not that expensive of a book. It's maybe like 10 or 15 lbs, II don't know, brand new or something, but you can get a second hand as well. Um I ha I have a PDF on my own. Computer. It's not that hard to get, you know. So it's a, it's, um, yeah, something I very highly recommend. I'll, uh, I'll write it in the, um, chat as well. Yeah, I believe that would be very helpful. I still can't see the comments for some reason. They are not, not updating for me. But, um, uh, I can see your, um, I can see your text though. Uh, that's fine. I can still read out if there's any questions. Um, a few. Thank you so far. Um, but I can't see any questions at the moment. No worries. You're very welcome and good luck for your exams. And, um, yeah, just keep on, er, revising practicing. Main thing with osk again. This is one thing that I didn't mention, um, is, uh, re repeat over and over and over, do the station over and over and over again, develop your own style, you know, speak with your friends, make sure you don't just stick to one friend that you do the sy practice with, speak to different people when you're doing your, um, practice. Uh, you'll pick up tiny little tips or thing ways of saying things better from different people. Um, each person is unique in their style, you know. Um, don't think that you have to be exactly like a specific person. Um, all they're looking for is that you're safe, you're a safe person, you know, as long as you, this is the other thing I wanted to mention whilst we have some ti time, um, how do you show that you're safe? So, I sh ii showed how you show you're competent, how you're professional. How do you show you're, you're safe, you sure you're safe by showing that you have a system in place. Someone could ask random questions all over the place they could ask, you know. Oh. you know, uh, how long have you had a cough for? Oh, what's your family history? Oh, what's your, you know, um, do you have chest pain or shortness of breath? You, 00, let me ask you about the cough again. You, they could move all over the place and they, technically, they could get every single point in the OSC that there is to get, but you're not gonna get global marks like that. You have to show that you have a system in place because the person who's assessing you, he's gonna think like, yeah, sure. They managed to get all of the Mark scheme this time. But the next time when they have a, you know, a patient, are they gonna be able to replicate the same results with this random system? If you have a process and a kind of structure to your history and it's very kind of methodical. That's how you show that you're safe. You've covered all of your bases in terms of the history. You've made sure to ask the different aspects of the history. Ok. So that's um that's the other feedback that I can give you. Ok, we have another question, any tips on cardiovascular examinations? Sure. So the main tip I will give you is um that you have to uh uh practice over and over again. Uh you can use, you know, often times I just do it on my bed. Um There's certain subtleties in terms of getting the patient to move forward, to move backwards and things like this, you can try and minimize the amounts of movements. Uh this helps you in terms of the time limit within the um, er, ay, um, the uh all I can say is it's a memorization exercise for your examinations. Um and you just have to go through it step by step and methodically. Um l you can listen on youtube to some of the, I used to listen to some of the uh heart sounds, you know, when they bring you patients with pathology, uh oftentimes like, um you know, um uh like a mitral regurgitation or something like this common or heart valve or something like this. So just learn some of the different um, murmurs that might er, arise um and some of the scarring. Um, and yeah, that's, you know, all it is is about exhibiting, exuding this kind of, er, professional confident demeanor. Um, you, you have to think that in that assessment, you are a, er, doctor, you're not a medical student. Ok. Forget all of the things that happened in the past that, you know, how you feel about yourself, all these kind of things for those 12 stations or that, you know, 1.5 hours that you're doing the ay, you are the doctor, you are in control of the room. You are, um, the person who's, you know, kind of the patient's coming to you for help and you have to think about it very deeply in that way because if you, you know, if you show you that you are insecure, you don't know, et cetera, all of that is gonna impact your global market. Ok. Um, so, yeah, and um, what the other thing that I would say as well for, you know, um, some of the, since this is International, do Doctors Association for some of the more international, er, doctors, your accent, it does make a, a difference, unfortunately. So, unfortunately, so, um, you know, they've done studies on, um, Aussies and these types of assessments. Um, it does show that there is a bias against, uh, you know, people with accents, er, people of color, things of this nature. Um, you also, I can't give you a magical answer to say like, oh, it's ok, et cetera. It's unfair. That's how it is, you, that's life, you have to deal with that. But the things that you can change is making sure that you, um, practice your speech. So make sure you enunciate your um your voice correctly. Make sure you, there's no kind of like confusion in how you talk, talking slower, helps with that a lot. Um, and as well as that, you know, make sure that you have a few phrases that you can stick to and you can like, use as your um foundation basically if you can revert back to that rather than um, being all over the place. Ok. So, yeah, that's the advice I'd give to kind of um international uh doctors. Yeah, at the moment, we have quite a few. Thank you. And uh yeah, thank you. And good luck. You will be an an excellent doctor Rosette said. So um yeah, a lot of praise for you and the top, did you say I will be, I will be uh I, I'm already doctor Rosette said. Uh thank you and good luck you will be an excellent doctor. So, ok, well, II am already excellent. You already a doctor. I'm very humble. I'm very humble. All right. Thank you guys. Uh I can see that the time is up. But uh yeah, I wish you guys all the best. Thank you. And please fill out the feedback form. II would very, very much appreciate good feedback. So yeah. Oh, any feedback, any constructive feedback? Indeed. Uh Yeah, I think that this uh marks the end of our session today. Thank you very much again, Doctor Sam. And uh once again, please fill out the feedback form to get your, um, attendance certificate as well. And yeah, we will see you next time. Um, if you want to know more updates, follow our metal page and, uh, we will update you um, on our future sessions and that's it from us today. Goodbye now and have a good rest of your day.