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About the exam and a bit about some like next step, investigations you wanna be going through. So what happens on the day? So the gastro history and gastro exam is, is guaranteed to come up. So it's very important to learn, learn this well and you be prepared for the rest, cardio, neuro and gastro exams. There's no point like not preparing like properly for this is gonna come off on the day. Um So the history station, so how it works is on the day you'll get like a short prompt. They'll be like, ok, this 65 year old man, this 30 year old woman has come in with abdominal pain, take a quick history maybe present, you might have to present and then you'll have two minutes for questions, that sort of thing. Um So the structure of the history is the most important thing when you're doing when you're doing your sy if you go through the structure like properly, um, you can't fail. So I'm sure you all, you all know this already, but you do your introduction where you explain what you are, who you are, what you're gonna do. You do your presenting complaint and your history of presenting complaint. Then you do a quick summary. I've started these because I think these, this is the most important part of the history. This is where you're gonna get the most information and show what you can do to the examiner. It's super important to let the patient speak as much as possible for like two and three. And you're gonna do like a specific Gastro Systems review. I think they teach you to do a systems review at the very end. But I think it's always good to do a specific Gastro Systems review after your summary, cos it just um you just rule out any serious gastro red flags at the beginning and in case you run out of time, the examiner can't say, oh look, this guy hasn't done it. This guy hasn't done the system with you. Um Then you want do your past medical history. You want, you wanna do ice, I've started ice as well because you wanna keep ice quite fluid throughout the consultation. Um Then you do your drug history, family history, social history, final systems, you then you close. So we'll go into more depth on each of these. So introduction. This is super important because first impressions are incredibly important on the day. You might not even, you don't even have to be that good. But if you show you're a good person, you're a good doctor. Um You know, you're just a good human being. You, you're, you're likable, you're gonna do much better than people who just come in like a robot on the day. You're just gonna, you're gonna do so much better. So it's important to smile, you know, show that you're show who you are, like show you're a good person. Um, explain who you are. So hi. Hello. My name is, you want to say your full name? So I would say hello. My name is I'm 1/5 year medical student, but just be careful because on the day this could change the short prompts. They give you, they could tell you that you're f one that you're a student, you're a consultant. You don't, you don't, you know, probably be an F one or student. Um You wanna lay out your objective, you need to say what you're actually gonna do with the patient. So I'm just gonna have a quick chat today about why you come in today. That's enough. You obviously need to confirm the patient's name and date of birth. Um ask for consent. So after you've confirmed the name and date of birth, you'll, you'll say, ok, is it ok? If we can proceed, they'll be like, yeah, and then I think it's all you have to do confidentiality as well. So you'd say anything, I tell you remains confidential, anything you tell me remains confidential between myself and the healthcare team. It can't just be confidential between myself because I will pass that information on to the healthcare team and then you want to just check for a final, um just get a final consent. So I've made these little green boxes throughout the presentation. They're just like communication tips and like nice things you can do on the day to stand out to smile. I think it's good to lean inwards with the patient. It shows that you're more involved with the patient. Um and eye contact is super important. So now this is really important. This is the presenting complaint. You're gonna find out why the patients come in. So start with an open question. Very important to start with an open question. OK? Can you tell me a bit about why you come in today? Very important to show empathy. They're gonna say something bad like I've got this bad abdominal pain, I've been vomiting and diarrhea. If you just say, OK, then that's just an instant red flag. You gotta be, you gotta show some empathy even if like you don't mean it on the day, you've just gotta say it right. Sorry to hear this. That's not be really difficult to hear. You just gotta show the patient and the examiner that you're showing empathy, ask the patient to expound. Can you tell me a bit bit more bit, a bit more about this? Just keep uh asking open questions. Now don't interrupt them as well and this is like an aar point. But if the patient says like, OK, look why have you come in today? Oh yeah, I've got abdominal pain, but I've also got this knee pain. I've also got this rash on my back. I've also got this, this, that it's important to set up a shared agenda. So it'll be like, OK, I think it's important if we tackle this today, your abdominal pain and on a on a further laser consultation, we can do this. So now a history of presenting your plate. So all you need for this is Socrates. If you do nothing but Socrates, you're gonna do great. You do great Socrates is all you need. So you wanna ask about sight. Where's the pain? What's happening onset? How long has it been going on for? When did this start? Has it been getting worse? Has it been getting better? Ask about the character of pain? Is it sharp pain? Is it dull pain? Does it radiate anywhere? Does it maybe like appendicitis? It starts on the umbilical region goes down to the right lower quadrant? Um Is there, is there any associated pain with that? Um, time? How long? So explain the time course for me. Has it been getting gradually worse, gradually better? Is there anything that's making it better or worse? Like someone's got Gored, you know, eating fast eating spicy foods, acidic food is gonna make it worse, eating, slowly eating. Uh having like, you know, um a lot of water yogurts those kind of things are gonna make, make, make you a lot better. Um Ask you about severity. So always ask the patient on a scale of 1 to 10. How bad is your pain? So key gi symptoms, um these are very common on the day. So you might get a patient that, that could come in and vomiting or obviously abdominal pain, it's important to think about the following causes of vomiting. So infection is obviously a very common cause. Um but also go things like go can present with vomiting. You can get ac contact. If someone has a pyloric stenosis, you might get projectile, nonbilious vomiting. If someone's got a bowel obstruction, you'll get bilious, uh vomiting. If someone's got a pharyngeal pouch, you'll get like bits of food stuck in there that's coming up, esophageal stricture again, bits of food coming up. So bile, so you might get an example about bilious. It's important to know a bit about that. So Bile is obviously it's released from the um followed up into the duodenum. So any, any vomiting that occurs from above the duodenum is gonna be non bilious and anything below the duodenum is gonna be bilious, you're gonna get that green yellow on it because Bile is there. So anything above the duo? No, no, it's not, not bilious. Anything below it will be bilious for abdominal pain, you wanna know is it localized or is it generalized? Things like localized pain? Can can point to specific pathology like appendicitis is gonna be in the the right lower quadrant, obviously, things like anything to do with the liver, probably right upper quadrant, um umbilical umbilical epigastric region is gonna be things like go pancreatitis, but it could be generalized as well. Like you could have an IBD patient or you could have an IBS patient or you could have a peritonitic patient would be generalized, acute or chronic. So, chronic, things like IBS IBD, acute things more severe appendicitis, pancreatitis, biliary, colic, those kind of things. So this is where I think it's important to also think about the key upper ge key key symptoms. Uh So a patient might say they've got jaundice. So when you, when someone has jaundice, the liver needs to come to mind. Obviously, because of bile, it might be a bile bile obstruction. Too much bile is building up because it's been obstructed. That's what causes the yellow pigmentation. Uh hematemesis is, is like vomiting up blood. If it's fresh, like bright red, it could be a mallory. We something higher up. If it's more like coffee ground, it might be something like a peptic ulcer, duodenal er, gourd. You want to think about things like H pylori h pylori is the most common cause of go um alcohol. If they're drinking loads, right, they're gonna get certain food, acidic food, smoking as well. Dysphagia. Is it solids liquids or above? If it's both, I, if it's both when the young, it's probably something like achalasia, something more benign. But if it's like solid and then it's slowly going to liquids, then it could be something like malignancy that's important. Same for, same for odd of Asia, painful swallowing. If it gets worse over time, it's pointing to malignancy. Ok. So, now lower gi symptoms, so distension, that's like where your tummy is, like swollen. Right. It could be ascites, obstruct a bowel obstruction in women. Um, if they feel like they're bloated, it could be ovarian cancer. It's not really, not too relevant now, but it could be a differential that, that, you know, if it, if it comes up, um, constipation is a ask about diet now because diet is super important. So, like, ask about gluten, ask about, um, fatty foods, ask certain things, uh, are they on, on any medications? Certain medications I'll talk about to you about this later can lead to, to constipation, diarrhea, it could be infection. IBS IBD could also be cancer. Um, Steatorrhea, steatorrhea. Is that foul oily greasy kind of diarrhea, poo kind of, it's, it's not, it's not very pleasant and it's like a buzzword for pancreatic cancer or pancreatitis. But it could also be the patients on a fact drug like all of that or they've got a biliary obstruction, Melina, Melina, this is important. So for blood, if, if you got Melena, which is, which is blood in the feces, but it's like a darker, it's like a much darker diluted kind of blood that's gonna point to an upper gi bleed like, um, esophageal tear or like an ulcer. If you've got like hematochezia, which is very fresh, bright blood, that's gonna point to something much lower down. Maybe like a hemorrhoid or a fissure or even colorectal cancer or diverticulitis. Systemic symptoms. These are important, especially when you're doing a systems review for cancer. Someone's got like weight loss, fever, night sweats, tiredness, losing weight. Think about malignancy, apthous, ulcers, ulcers in the mouth because of Crohn's. Remember Crohn's is inflammation anywhere from uh mouth to anus. Uh Yeah. So it's important to know about some sometimes abdominal pain or gi symptoms. They're not always gi related. Someone could come in with uh really bad nausea and vomiting but it could be DKA or it could be because they've had really high like high calcium, you know, high calcium, you get abdominal bones, stones grows. So it could be like abdominal sorry. Um abdominal pain, you could have a AAA and aortic aneurysm. You might have an ectopic ectopic pregnancy, testicular torsion, abdominal bloating. Remember I mentioned it could be even ovarian cancer. Uh This is a little pain map I made but you can have a look at this in this, in your own time. But when the patient on the day comes up and says I've got this, I've got this pain here and there. Um that can help you on the day, just kind of rule in, rule out kind of send things. So, so after you've done your presenting complaint, um and your history of presenting delve deeper into it and then after you want to do a summary, so ask the patient, tell the like, explain to the patient. OK. I'm gonna, I'm gonna do, I'm gonna do a quick summary of everything you told me, feel free to jump in if there's anything I've missed. Is there, is there anything else that's important that you'd like to mention to me? It's good here because it shows the exam on the patient that you listen and they've actually, you actually know what they say, right? It's quite a, it's a nice thing to do and also it helps your train of thoughts. Also, it's also nice to a ask if they wanna add anything else after the summary. The first summary, it's important to do a gi test and review. So it's important because these things are like real hazards. Um Just um sign process to the patient. I'm just gonna ask you a few, yes or no questions. That kind of thing. Would that be OK? So I always like to start from the top and go down. That's that way. You don't really forget anything. So start at the top. Have you had any dysphasia that's important for esophageal cancers change in bowel habits. Um Very important for colorectal cancers, pain, jaundice, pancreatic cancer masses just malignancies in general, weight loss, malignancy in general, fever, malignancy in general. Ok. So this is the, yeah, these are the first um ment questions. So if you could just join this and then I can start asking you some questions. So, yeah, what do you think is the most appropriate way on the day to introduce yourself to your patient? Ok. I gave you uh 20 seconds. Yeah. So it was uh d always important to say hello when you're not just hi. Very important to say your full name here. Don't just say my name is John. You want to say your full name here? Because there's many, there could be many of you and explain what you are. Ok. So next question is, what's the vomiting? Ok. Let's have a look. So the right answer is c I'll explain this. So remember anything under the duodenum is gonna be bilious. Ving cos that's where bile is released. Bile enters your gi gi tract into the duodenum. So, a pyloric stenosis is to do with the tightening of your pylori in the stomach. That's above the duodenum. That's not gonna be bilious, gourd your stomach into the esophagus. That's again, not, not gonna be bilious. That's above the duodenum bowel obstruction that is below the duodenum. So that's gonna be bilious, vomiting, pharyngeal pouch all the way to the top. It's not gonna be bilious, vomiting, gastritis against stomach. It's above the duodenum is not gonna be uh bilious vomiting. Ok. Next question is which of these is a cause of Melina? All right, let's have a look. So, the correct answer is E E as a duodenal ulcer. So any, any upper gi bleed is gonna be Melina, any lower gi bleed very low is gonna be hematochezia most likely. Um, so duodenal ulcer, it's an upper gi upper gi bleed. So, and everything else, hemorrhoids, diverticulitis, anal fissure, even ulcerative colitis, it will present with hematochezia. So, ulcerative colitis commonly affects the um the very end of the gi tract. So a so around the sigmoid sigmoid colon and under that and that's why it's a lower gi. So, yeah. So next question. So, yeah, 72 year old man presents with painful swallowing, weight loss and night sweats which have gradually worsened over four months. He's got a thirty-year smoking pack history. What is the most likely diagnosis? Ok. Give you 1520 seconds. So the correct answer is d this is an adenocarcinoma of the esophagus. So I'll tell you how you get there. So this is this picture. This is like a malignant picture. You're old, right? Achalasia commonly affect younger people. They'll present much, much younger than a 7272 year old man would. Um So 72 year old man that painful swallowing. So that can, that's quite common. Very, it's a very common symptom when you get when you get um an esophageal cancer weight loss, night sweats, these are all b symptoms of cancers flaws. Um Now the important part of the question, the way to distinguish between B and C because those are two types of esophageal cancers. So, uh it's between an adenocarcinoma and a squamous cell carcinoma. So, a adenocarcinoma is at the top end of the esophagus and a squamous cell carcinoma is at the bottom half. So the way I like to remember this is anything you put into your mouth, like smoking or alcohol is gonna increase the chances of having an upper esophageal cancer. Anything that's coming up from the stomach like Gourd Barrett's esophagus, h pylori, that's gonna increase the chance of a squamous cell carcino, which is the lower esophageal cancer because he's smoking, he's more likely to have an adenocarcinoma rather than squamous. There's not, there's nothing to mention on go, anything like that. So that's why it would be B OK. Number five is 26 year old female presents with acute severe, 10 out of 10 left flank pain and hematuria. E and these are done and she's got raised calcium. OK. Let's have a look. It is. B so she's got a renal stone. So anytime you, anytime you see severe 10 out of 10 left flank pain, it's probably a kidney stone. So kidney stones are notoriously really, really painful. Hopefully, I never find out how painful it is. But um, appendicitis is also very painful. They're all painful on this list. DNE are not too painful. But first of all, she's a, she's young and she's a female, females are an increased chance of getting stones in general. She's got flank pain, which is quite a giveaway. That's where the kidneys are. That's where her stones most likely to be in the ureter, up, up in the kidney, down the, in that, in that flank kind of region. Um, in topic, pregnancy, you'd need to have a bit more information on maybe a positive pregnancy test. Um You need a bit more information for that one. Diverticulitis. Typically older you get more, not as severe pain as that you get blood, maybe in, in the stool, those kind of things as well. Um This is not a UC picture, raise calcium. So calcium is typically high when you have a renal stone because the main, the main um stone is like the most common stone is a calcium oxalate stone. So you typically see raise calcium in a kidney stone. So now we're on to the past medical history. So ask about any general health. Are they eating the apples a day? Are they keeping you away from the doctor? Do you have to go in to see the doctor a lot? Uh Do they have any health conditions, previous hospital visits? Any previous surgeries? Think about risk factors here. You know, if they've got um go that's a risk factor for barrett's, that's a risk factor for esophageal cancer. If they've got a low fiber diet. It's also a risk factor for quite a few things. Um, ok. Ice quite fluid. You wanna keep this fluid throughout the consultation because you wanna keep it natural patient centered. If you do it all in one go, it's not really is good. It doesn't seem as good, it seems a bit forced. So you'll pick up on cues during history as to when you'll ask about idea concerns expectations. The patient may be like, uh, I, I've had a look on Google, I think it might be this and you'll be like, ok, is that your idea? Do you think that's what it is? So, always ask about. Do you have, do you have any ideas of what, what might be causing this? Is there anything in particular you really worried about? And what would you like out of today? Drug history? What drugs are they on? Have they had any recent changes to their medication? It's, you have to ask about drug allergies. If you don't ask about drug allergies. I'm not sure if it, I'm not sure if it's a failure, but it's super, it's very, very important. I don't think it's a failure, but it's very important, very, very important to ask about drug allergies over the counter medication. Are they on any, like antacids? Are those kind of things? Are they on nsaids? Remember? Nsaids, if you're taking NSAIDS, loads and loads, like if you've got someone with a muscle pain, inflammatory pain. And you're taking like like four paracetamols a day. I mean, two ibuprofen, not paracetamol, ibuprofen loads of Ibuprofen a day. Um It's going to increase the chances of getting an ulcer, peptic ulcer, um, contraception. So if you go to a woman of childbearing age, ask about contraception. Um and also side effects. So certain drugs like opiates will cause constipation. SSRI s will cause constipation. Antibiotics may induce jaundice. And like I said, nsaids ulcers and it's a very important to ask about illegal substance as well. It's something I must ask. But we have to ask everyone, this is there any chance you've taken any illegal substances recently, family history. This is very sensitive. So it's very important to signpost here. You want to warn the patient, you're about to ask about their family history, their mother or dad might have died from a gi condition you just don't know. So the way to signpost is some say something along the lines of, you know, it's really useful for me to know a bit about your family history. Would you mind telling me a bit about if you, any of your family have had any gi conditions um social history. So you wanna work out the smoking pack years. This is an, this is an important skill when you're presenting. So if you, if someone smokes there's 20 cigarettes in a pack, right? So if someone's smoking 20 cigarettes a day for a year, they have a one year smoking pack history. If someone is smoking 10 cigarettes a day for 10 years, they have a five year pack history. So, alcohol units, um, it's important to learn about units as well. So just have a look on, on online to know about how many units are in a pint, how many units in a glass of wine in a shot, those kind of things. Diet. Um, Low fiber is very commonly associated with colorectal cancer. Uh Gastric cancers, gluten is gluten. What's what's causing the flare ups? They may have celiac in that case, fatty foods. So they're getting really bad, sharp, right, upper quadrant pain when they're eating fatty foods, it could be biliary, colic travel pretty important as well. So now you wanna do a final systems review, go from head to toe. So I always start with neuro, then I do rest and do cardio, then do gastro and a closing. So last impressions are super important. Um just as the first impressions are important. Last impressions are also important. So it's good to summarize, check, summarize again, ask if you've missed anything, ask if they have any questions or concerns and then thank the patient for their time and smile and it's quite nice to say, look, it's really glad you've come in today and we'll now do the best we can for you cos that's just a nice way to end it. So we'll do these do, we'll do these S PA S at the end cos um I wanna finish in time and yeah, at the end. So now going on to the examination station. So at the same amount of time, you'll be given a short prompt again. It might be something like a 50 year old man has come in with abdominal pain, severe abdominal pain, please complete an abdominal gastro examination with this patient and then present. So it's again, seven minutes. They say eight minutes for the examination, but try and do it in seven minutes. Cos then you have at least at least a minute for a presentation. You can do a presentation in 40 seconds, 30 seconds, but it's risky. So try and make sure you just get your examination done in seven minutes. You don't wanna be in, in nine minutes and then you're just, then you're done. You're not gonna get any points with the questions. What's the point? No, because the questions are quite easy as well. So, so two minutes for questions as well. Yeah. So this is the structure. So you'll get used to l learning the structure. It's obviously it's really early in the year, but you'll know you'll become more familiar with this later on in the year. Don't worry too much about getting it. All right. It's, it's important to make mistakes and by the end of the year you'll just get into the habit of knowing the structure and just being like a robot basically. So again, introduction, then you wanna do a general inspection. Look at the hands, there's a lot of pathology you can find from the hands. Look, look at the arms and the underarms, the axilla, look at the face, the mouth, the eyes, OK? The neck. Um you'll be looking at lymph nodes in the neck. Well, no, in particular, when you look at the chest, they looking for things like gynecomastia, spider nevi. And you want to do an abdominal inspection, any scars there, any masses ascites. Um Yeah, those kind of things about megaly, um abdominal palpation, you'll do light and you'll do deep palpation and you'll do liver palpation, spleen uh gallbladder. You won't do bladder, you have to offer bladder, but you won't do it any time. It's a bit, it's a bit invasive. So you just offer that and then you'll also need to do um spleen um then abdominal auscultation. So sorry, percussion. You need to do liver percussion, um splenic percussion and you also need to do shifting dullness test for ascites. Then you'll do an abdominal auscultation or you listen for things like bruise and just regular bowel sounds. Then you look at the legs of pitting edema. You look at the legs for, I think it's definitely due for cardia as well. So that's important. And then, then you just, then you then you're done. So again, so introduction. So again, first impression is super important So smile, wash your hands. So for the examination, you need to wash your hands. If you don't do that, that's like one mark off. That's an easy mark. Wash your hands. But like so many times in practice I feel I need to wash my hands. It's, it's an easy thing to do. So just wash your hands. Um Explain who you are, what you're going to do to them. I'd just like to carry out an abdominal examination um of you today as so you want me having a look or feel um a tap and a listen. Uh Does that sound? Ok. Um Confirm your name and date of birth. Um Explain the examination may be slightly uncomfortable, it won't be painful, ask if they're in any pain. So when you're doing like your general inspection from like hands, um face, et cetera, you wanna have the bed at 45 degrees. It's only when you get to palpation where you want the bed flat. So for rest and cardio, I know it's at 45 degrees. Gastro is the only one where you need it flat for palpation, but the initial parts are done at 45 degrees. And also you need to adequately expose the patient to explain. I just need you to be um exposed from waist upwards. Does that sound ok. Would you like any help you would, would you like me uh to help you take, take your, take your top off that kind of thing and ask you if there are any pain, you can also offer them painkillers now as well. So things are looking on general inspection, clinical signs. So do they have any scars? Have they had any previous surgeries? So previous surgeries increased the likelihood of things like adhesions, which can then increase the chance of things like construction and you know, those kind of serious things. Um Do they have distension? Distension? Could be a sign of just general constipation? It could be a bowel obstruction or it could be something worse like ascites. Uh Are they pale? Do they have anemia? Are they jaundiced? They have hyperpigmentation? Some things like Addison's um edema again is is to do with cirrhosis and cachectic. So super skinny. Um not much muscle there, just bone that's linked, that's, that's linked to things like anorexia or malignancy and then objects and equipment. Do you have any feeding tubes? Stoma bags, ability aids? OK. I went to the hands. So you wanna look at the palms first, so get them, get the patient to have their, their hands um laid down in front of you. Uh You wanna look uh things you wanna look for are pallet just general pallor. Is it, are they looking pale? Could be a sign of iron deficiency anemia, malignancies. Then you wanna look for palmar erythema. So palmar erythema is like a thickening and like a this is the first picture top left that's palma, inner femur, it's a thickening and a redness to the palms. It's a sign of chronic liver disease. Du's contracture is a sign of heavy alcohol. A so in alcohol addict, they'll get Peen's contracture where they've got um an excessive fascia building up and tightening of their, their palm which has led to their finger sticking upwards and it's stuck in that position onto nails. So ask them to flip their hands over, look at their nails. So kochia is on the left. So caine are like spoon shaped. Um It's a sign of iron deficiency anemia. They all look like spoon shaped nails, very round nails. Leukonychia is when you've got the whitening on the nails and that's a sign of liver failure. And then clubbing, clubbing is the buzzword, isn't it? You have to do clubbing, they love it, the examiners love it. Um But the free sea. So clubbing is a sign of the free sea. Um So IBD, that's Crohn's celiac and colorectal cancer. Um And then asterisks. So asterix in a cardio exam, I mean, sorry, in a rest exam would be co2 retention. But asterisk is flapping your hands out in a gastro exam would, would link to hepatic encephalopathy because of raised ammonia or high urea in renal dysfunction. You wanna have a feel temperature uh and check the radio pulse. You always wanna mention the rate and the rhythm on the day. If you can't get the exact radio, make make sure, you know, it just may have an even number. It can't be an odd number, just make sure it's an even number. Um arms and axilla. So now you wanna look at the things like needle track marks could link to things like hepatitis. Uh bruising could, could be things like um a platelet deficiency because of liver clotting deficiencies, um axilla. Um So acanthoses groans is like a darkening and thickening of the skin under the underarms linked to type two diabetes or gi malignancy. In particular gastric cancer and hair loss could be things like anorexia in anorectic patients you'll get you, they won't be producing much hair. There'll be very fine hair, lanugo hair it's called or it could be a sign of like a malabsorption problem. They may have, they may have celiac disease. Mm So now on to the face. So on the face, you want to look at your eyes and your mouth. So inside the in the eyes. So, conjunctival pallor, any time you hear pallor, it's gonna be anemia, jaundice. It's again a liver related corneal arcus and xanthelasma. So corneal arcus is like a, it's a very hard time to pick up, but it's the, it's a pre images. It's the one on the left. Sorry, it's the one on the right, the brown eye on the right. Um It's like a hazy hazy foggy eye. It's a very hard time to pick up Kaiser Fleischer rings. They're just a buzzer you're never gonna see in your life. You just need to know the exam. Even consultants haven't seen them. I don't even know why they teach it to us, to be honest. And then, and then you've got um Zamal Asma, which is these yellow kind of spots building up around the eyes as top image. That's a sign of too much cholesterol. They may have a cholesterol um um like a, like a congenital cholesterol problem or it could just be because they've got a high cholesterol in general. Um then on to the mouth. So things like angular glossitis and angular stomatitis and glossitis will be iron deficiency anemia and oral candidiasis. It only affects immunocompromised people. So, if you've got oral candidiasis, you know, they're immunocompromised pretty much and then apthous ulcers, they're just ulcers, but it's a sign of Crohn's OK. So now onto the neck. So you don't need to waste your time doing all the lymph nodes here. Some people did that and they wasted loads of time. The only ones you need to do are weals node and then you, you wanna feel the nodes in the right supraclavicular fossa. They're just like the little dimples in, in um near the clavicle region. So, Vow's node is on the left. That's very important. It's important to mention this in your presentation. So there was no signs of Vow's node node was not palpable. That's what you'd say. And vows node is pathic pretty much for gastric cancer because the lymph drainage from the gastric contents um go up to this node. So if you've got malignancy, they're very commonly gonna spread to this area and it become enlarged. So that's why you get fo node in gastric cancer. And on the right, it's common. It's more patho pneumonic of an esophageal cancer. But it's the buzzword is V node. That's the one you need to know And, and it's important to present that in your presentation. OK. Now, on to the chest. So Spider Nevi, you'll get a raised Spider Nevi happens because you get raised estrogen due to due to liver cirrhosis. Um you might get gynecomastia again, that's raised estrogen due to liver cirrhosis. The liver can't properly break down the estrogen. And so you'll end up with raised estrogen because it's eros it's your liver's gone at that point. And then hair loss again, that could be anorexia, malabsorption problems. So now you wanna do an abdominal inspection. So this is at this point, you wanna lay the bed flat at, at um did you wanna, you wanna take it from 45 degrees to flat? Very important to remember this. Um Look for um scars for surgeries. Is it distended if they got ascites, maybe obstruction? Um tut medusa um that links to portal hypertension and therefore chronic liver disease, stria which are stretch marks, could be cushing's or it could just be obesity, hernia. So you have to ask the patient to cough. Then you may see a hernia in the femoral region could be uh gastric hernia, could could, could arise there. So ask the patient to cough and look towards the lower the lower abdominal region and then colon sign. Um and gray turner sign are signs of late pancreatitis, but they're late because they are signs of hemorrhagic pancreatitis, hemorrhagic pancreatitis only happens typically very late. So if patient have these signs, you pretty much know they've got late onset of pancreatitis and it's an emergency. Um So now it's in the palpation. Um So you do liver palpation, you will do kidney blocker and you'll do spleen palpation. Um I'm not gonna go through all of this really. You're basically palpating upwards. You wanna start at the bottom in the right iliac fossa and you wanna get the patients to take deep breaths in and out. And every, every time they take a deep breath in, you wanna move your hand inwards and try and palpate in with your, your thumb and your, your finger, your p your index finger in inwards and try and feel and eventually you'll keep going up to the right costal margin and that's where you may feel an enlarged liver hepatomegaly. You shouldn't really though um and repeat this process moving all the way upwards, all the way upwards to the right costal margin. Um And then you wanna keep going up. Um And that, that until you feel something and I just listed a few courses of Bato megaly in the picture. So now, um, palpate in the gallbladder. So this is, this will happen at the same time as your palpate in the liver because the gallbladder is just under the liver. So you don't need to worry about doing two separate palpations. You, you do it all in one, all in one go. But the sign you're trying to elicit is Murphy's sign. So when you're up near the right costal margin and they're taking a deep breath, if the patient suddenly stops in real pain, it's a sign of Murphy sign and that's the cause of inflammation of the bladder. Could be because of gallstones in the bladder or it could be an um, an obstruction into the blood into the gallbladder. So, now spleen again, you wanna start in the right iliac fossa again, but this way you wanna work your leftwards because the spleen is on the left and the liver is on the right and you wanna keep going until you feel something, but you should not feel a spleen in a normal person. You'd only feel a spleen if they've got a splenomegaly. And I just listed some uh causes of again here. Ok. Now, both off the kidneys. So you wanna, obviously, you need to be on the right side of the patient, on the patient's right hand side. Um You wanna make sure you, you get your a comfortable hand onwards and you have a hand onwards on the top and you wanna kind of be be pushing your hands inwards, trying together and trying to feel some, feel, feel the kidneys. And again, I just listed the cause of enow kidneys. Yeah, these are, it's important to know these causes for questions. If you know them, they are easy marks on the day then onto the aorta. So if you can feel that uh aorta and it's, and it's um you can, you can feel that thing like beating, then, you know, you've probably got a AAA on your hands and that's a abdominal aortic aneurysm. That's an emergency because if it bursts, if it ruptures, then the patients in real trouble. Um So again, you wanna kind of be going two centimeters to three centimeters above the um um um the umbilicus and you're gonna be pushing quite firmly into them. Mention it will be uncomfortable to the patient before you do it. That's important because it is uncomfortable. Uh very important because they'll be quite shocked by how, how, how like deep you're going into them, it, you'd have to apply quite a bit of pressure here. Um Just offer bladder palpation. You don't need to do it. Then the bladder could be because of just retention or it could be an obstruction like a prostate problem or malignancy. So now percussion, so percussions, you do liver, you off bladder percussion and you do shifting to illness. So, for liver, you wanna start from the left iliac fossa? Sorry, that's a mistake. You wanna start from the right iliac fossa. Um I'll change that. You wanna start from the percuss upwards from the right iliac fossa until resonance changes to dull. So if you've got, if you've got something resonant, it means there's not really much going on there. If it's dull, that's a sign that there's something solid there. That's a sign you've got, you, you've got to the liver. So when you get to, when it changes from resident to dull, you know, you've reached the lower border of the liver, you wanna measure that point up to the upper border of the liver because when it changes then from dull to resident, and again, it means you just pass the liver and you can measure that point to measure the size of the liver and measure the Hepatomegaly. So spleen percussion again, you wanna percuss kind of in an upward direction from the right iliac fossa. When it changes from re to dull, you know, you've got to the spleen, but in a, in a healthy patient, you will feel liver, but in a healthy patient, you should not feel a spleen. It's important to note that offer a bladder percussion and then for shifting dullness. So this is an important test. Some people mess it up. So shifting dullness is how you test for ascites. Once you understand it it becomes easy. So, ascites is fluid in the uh the abdominal cavity common with cirrhotic patients. Um So, what you wanna start with is you wanna percuss from the um from the uh umbilicus to the flank region until it becomes, until it goes um resident to tell a resident um is a sign, there's not much, there's not much there. And when it becomes dull, it means you probably reach the fluid. So that's where you wanna stop. You wanna keep your finger on that dull point. Once you keep your finger on the D cor, you wanna ask the patient to roll over away from you, not towards you. Sorry, you wanna ask the patient to roll towards you. So they don't fall over as well. They might roll over the bed if you want to ask the patient to roll towards you. Um Then you wait 30 seconds and then you repeat the percussion. If the percussion changes from resident has changed from down to resident, you know, they probably had ascites, probably, they probably got ascites because that fluid has then shifted away when they rolled over and that's what's caused a change in noise. Um If it's, if it remains, um if it remains resonant the whole time, they, they're probably OK, they haven't got CT S now with the abdominal auscultation. So you wanna use the diaphragm to listen for bowel sounds. So just listened, a few noises are normal will be like gurgling, tingling could be like obstruction and absent is not good. It could be paralytic ili mention it into the men. Mention the exam. I would ideally listen for three minutes, but in the exam, it's gonna be more like five seconds. Then you wanna listen for aortic and renal bries. So the aortic bre will be two centimeters above the uh umbilical region and then renal bre about 2 to 3 centimeters either side of that. And you wanna listen with a bell diaphragm for just general sounds and then the bell for bruise and then legs. So if you've got pitting edema, it's a sign they've got low albumin and that's because of liver cirrhosis and then you're pretty much done. So, explain to the examiner patient. Thank you so much for your time. I know that might have been a bit uncomfortable. The examination is now complete. Do you have any questions? Um You can now get dressed. Would you like me to help you with that? Wash your hands again? Ask, are they in any pain? Could I offer you some painkillers and then you're done? Um Yeah, so that's um that's the talk done. So thank you guys for coming. I appreciate it. I know it's like super early in the year. So it's good that you've come to it in the first place. I'm pretty impressed. Um I didn't think I was coming to these talks this earlier on in the year, but if you start early, I think it's a good idea to start early of your osk because then you just get into the habit. If you're starting late, it's quite, quite stressful towards the end. So, start early on this. Um And it's not too bad. It's quite, it, it, it, if you start early, the exam's fine. Um And we can just do those, uh BS if you would like or if there's any questions I can answer any questions. Um There's a question in the chart um could applying pressure cause a trip to rupture. Yeah. So that's why you don't want Yeah, it can, it can, it can cause a trip to rupture. So that's where like you've obviously got to apply enough pressure to feel it. But if you feel it, if you can feel it pulsating and then you, you wanna, you wanna stop, you wanna keep going further and further. So you shouldn't have to press so hard to feel it pulsating. But once you feel that pulsate in and you know, then you wanna stop and uh yeah. Is there any other questions? Um Will the slides be available? Yes. The recording will be available in a few days, I believe. Yeah. So why don't we just um go through these last questions? Uh We don't need to, we don't need to go, we can just go through it together. Um So gee medics is actually really good for like knowing all your relevant medications for the OS exam. Um, gee medics has got a lot of good information. So definitely use geeky medics for like knowing what medications could cause certain side effects for each of these stations. So the first question is like, um, which of the following medications will not cause constipation as a side effect? So, opiates Ondansetron, which is an anti sickness tablet will stop your vomiting and iron supplements will all cause constipation. Antibiotics won't, but they may cause jaundice. Um So if a patient has constipation in the exam and you tell the examiner that it could be because of a drug, they're on, they mention a drug that will really impress them. That would, that would show you that you know your stuff, the presence of familial adenomatous polyposis increases the risk of what. So, for me, this is a good thing to know for family history. If a patient mentions they have familial adenomatous polyposis, it significantly increases the risk of you getting colorectal cancer, not the others. And then is it appropriate to offer your patient painkillers at the end of a consultation? It absolutely is appropriate and it's a good thing to do. It shows the patient and the examiner that you care about the patient. Um You know, your optic, the, the fact that they have pain. It's just a nice thing to do as well. Yeah, that's, that's it. Yeah. Fantastic. Thank you so much. Um Lovely. Um Everybody found it super useful. Um I've just sent the feedback form in the chat. Um If you.