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Hi guys, my name is and I'm a, I'm 1/4 year medical student and today I'll be taking you through the respiratory station of your ay. If you have questions at any point, please feel free to type in the chat or if you have any questions afterwards. My email's on the screen. So you're free to email me and I'll respond quite quickly, to be honest. Um, um, one sec. So in this session, I'll be covering a few things. Uh I'll start by going over how to focus history. I'll then go over the overview of all the steps of the station. I'll go over a detailed explanation of each of the steps, step by step. I'll go over the signs and some symptoms to look out for. I'll take over a look at some common pathologies and I'll teach you how to interpret an X ray as this comes up at the end of all of your exams. Um, what they're testing is your ability to explain the procedure and gain informed consent, your skills in examining your knowledge of why we do each section of the examination, your ability to summarize all the information you've gained during the examination and then your knowledge of pathologies and how to read specific scans. So, the respiratory exam is one of your four exa er core exams, which means it is, it'll definitely come up. It's quite an easy exam, generally speaking. And with enough practice, you should be able to do it quite well. It's a, all your exams including this, you should focus a fair bit of time on them cos they are quite easy, easy to perfect. And the best way to perfect it is to just keep practicing again and again, the station is 10 minutes long with about seven minutes of it being for the exam, one minute to present your findings and two minutes for questions. I recommend aiming for about six minutes for the core exam part because odds are you will mess up in the heat of the moment because it can get quite nerve wracking. So I recommend aiming for six minutes in your practices which will let you finish on time in the real thing. And like I said before, just practice, it's all good seeing a lecture like this to do your Aussies. However, in reality, the best way to do well is practice on people and you spend a lot of time on the wards and I get that it can be a bit boring but patients are the best people to practice on because in your Rosky, the pa the actor will act like a real patient, they can have pathologies and they might be slightly resistant, which is why you should, the best person to practice on is patients your friends are good for getting the basics down. But at some point they end up, um, they know what you're gonna do beforehand, which a real patient wouldn't. So it's best to practice on patients. So, like I said before, I'm just here to give a quick uh overview of what they're testing. So they're, they're testing your, your ability to injure yourself and gain appropriate consent from the patient, then they're going to be able to, then the next parts are checking your surroundings and general inspection. Having a closer look at the patient, looking at the arms, face neck and then the core bits of the respiratory exam are the chest expansion, percussion, uh vocalis auscultation, the back and the legs and then obviously some summarizing the findings. Um So when it, the first step is the introduction and consent. And um so the first thing you do is you wash your hands. The basic step for every single exam is to wash your hands, it'll at best gain your mark at worst, you lose nothing, washing your hands. So there, there'll always be a bottle of hand gel, they'll win the room, use it. Um The next thing to do is then introduce yourself. You do this. I like it here. So it is say your name and your role for example. Hi, my name is Alec Pra and I'm 1/4 year medical student. You then confirm that it is the correct patient. You asked for their name and their date of birth so that you're talking to the right person because you don't want to be doing it on the wrong person. The next thing to do is then explain the procedure to the patient in whether they can understand. For example, your doctor's asked me to perform a respiratory exam on you today which involves me having a look, feel and listen of your chest. So explain what you're doing. Say it in a simple word that they can understand. Don't use medical jargon because this will confuse them. The next thing is then to explain the exposure cos it's a critical part of the exam, tell them that they need to be exposed from the waist up. But women can keep their bras on and offer them help to also get undressed. Uh In each exam, you should also offer a chaperone, say the examiner will be a chaperone. This is something that should be offered in any exam that requires removal of any clothing. It's to protect both you and the patient. So you always offer this and then from here you move on to informed consent, make sure that the patient understands what you've actually said. Ask them, do you understand what I've told you? And does this sound OK to you? Cos they might have issues with it. So always ask them this. The next thing is then mention the angle of the bed. So for the thing for the respiratory exam, the bed needs to be at a 45 degree angle. And in the exam, it's possible that they'll lie the bed flat in my exam, the bed was flat and they expect me to put it up. So watch out for this, it can happen. The next thing is then to ask the patient if they have any questions. So because they might have a question about something you've said or after the procedure and then ask them if there are any pain, similar thing, always ask them if there are any pain. Um So the next would be the general inspection and I've got a men on the screen and it would be great if you guys could just put down some answers of what you'd look for in and around the patient in a general inspection, I'll just wait another 30 or so seconds. It'll be great if you guys to put down some answers. I've got, I think one or two responses so far. Ok. So someone's written down a couple of answers here which are central cyanosis scars and the use of accessory muscles. These are actually part of the closer inspection where you look at the patient's chest and at their face and arms and that comes up along a little bit later. So the general inspection is more about the patient, how they're presenting in the moment stuff they might have around the bed. So look at the patient themselves and look at how they are generally up. Do they seem comfortable? Uh they short of breath? Are they wheezing? Does speaking make them uncomfortable? Um Are they CEX sick? Then you also look around the bed, like I said to look for stuff like medications, uh inhalers, spirometers, anything that relates to any disease, but also generally specific to respiratory illness and make it quite obvious versus also inform the patient tell the patient, I'm going to have a look around the bed and look around, make it obvious, think of it like your driving test. You don't exaggerate the movements so that you look at, look around like this. So the the examiner knows that you are having a proper look around it, it does feel a bit weird to do it, but it shows the examiner that you are, you know what you're doing in the moment. Um So from here, I normally move on to closer inspection. You don't need to do this in this or necessarily some people prefer to do it after they do the er face and neck. But the the next, the way I did it was to go into closer inspection. So as the one of you had mentioned earlier, you look, this is the way you look for stuff like scars and these are accessory muscles. So once again, inform the patient, tell them, I'm now just gonna have a look, a closer look at your chest. And the first thing to do is ask them to put their hands to their sides so that you can see the entirety of their chest. Look for signs of scars, deformity, wasting circulations, uneven movements, use of accessory muscles. And then once you've done this, have a look, once again, similarly, look around, look on the opposite side of the patient as well, cos you're standing on the right side, but it's possible you might miss something on the side underneath. And then after this, ask them to raise their arms upwards because you also need to look in the axillary region. There might be scars or any issues in the axillar as well. And then office also ask them to lean forward because there can still be um pathology of respiratory disease on the back of the patient. These are a few types of scars that uh you might see such such as the midline Steny and the anterolateral thoracotomy. So if you see them mention them, you don't n it's good to learn these, learn lists of the scars that you could see on the patient. But even if you don't, it's good to be able to notice them and mention them. So from here, you'd move on to the hands and the arms. And once again, I'd like if you guys be able to just go on to the Inn and the, sorry, the men and put down a few things that you think you'd look for in the hands and the arms of the patient and for anyone who's just joined a little bit later, I'll just put down the mental code in the chat because it was on earlier slides. But I've not gotten the later slides. I just give it another 20 or so seconds and then, and we don't. Ok. So someone's put down a few answers which are tar dating, clubbing and tremors. And these are things that you do look for in the hands and arms. So once again, sign person, the patient, what you're gonna do now, I'm gonna take a look at your hands. Look like you said, look for Tar sing, clubbing, peripheral cyanosis and tremor. Um For Tar Sating, just take a, basically take their hands and look at their fingers see if there's any dark marks on either sides of their hands, on their fingers, which signifies cigarette use. Uh For clubbing, we do the window test. The window test is where you ask them to put their fingers together like this. And I've got a class, it's hard to see, but there should be a small gap um above their fingers, which is in all, in all patients in patients with clubbing, this disappears. But even then the clubbing tends to be quite obvious because the patients, things will still look fatter than normal. Um, similarly peripheral cyanosis, look at the fingers, see if they're blue or black, color change in color pretty much. And also tremor, ask to see how the patient is. When they put their hands out, they've got a fine tremor that can um indicate more use. Um You'd also do the capillary refilled er times. So this is where you take the patient's finger and just pinch the end of it like this for a few seconds and then watch how long it takes for the color to enter the finger again, which is the blood returning. It's generally under two seconds in a normal patient, anything significantly above this is called a concern. The next thing is in to you ask them to put their hands up like this and cut their wrists back like this. And the aim of this is to look for a, a course tremor which is flapping caused by CO2 retention. Um From here, you also then look at the temperature when the arm is already outstretched, put your hands a uh along from this sort of proximal to see if it uh check for the temperature on the back of your hands to see if it's normal. Also look at check their radial pulse. So just as normal as you most you would know, press there and time it for for 15 seconds and then while you're doing this straight after, also count their respiratory rate, but don't tell them keep on taking their pulse or do something else. Don't inform them of that. You're taking their respiratory rate because then they'll start to think about it. I don't know if that impacts it. Both of them count for about 15 seconds. You should have a watch in your exam and make a mental note of it. Worst case, think of a number for both that, you know, divides by four and then use that because you, you, you will need to mention it at some point and a normal rest rate is between 12 and 20. And then you also a I recommend you thinking about it as moving up the arm. So and then around here you think about taking that BP off to take it. Odds are they'll just tell you the BP, they won't require you to do it in the exam itself but offer it. It's always a it it is a mark, it's a good thing to offer. So here are some hand plans I mentioned before. So peripheral cyanosis, like I said, and then also clubbing and there are, these are a few causes of clubbing, uh such as broncho carcinoma and um fibrosing alveolitis. And the image shows you what it looks like for a normal finger and a clubbed finger. So that's the sort of thing you look out for. OK. So then from here, you then move upwards, you move into the face and the mouth and once again, uh put down some answers on the mentee as to what you think um you'd look for on the face and the mouth. OK? So once again, inform the patient of what you're doing at each step, you need to just inform the patient sign the post so that they know what's happening. So you don't confuse them. So tell them now we're gonna take a look at your eyes, your face and your mouth. So in the general face, you should look at the general shape, what it looks like to look for edema, which would be fluid, their face would look swollen, similarly, cushion roid features such as moon face, but they have a round face. Um look out for these um then you move on to their eyes. So common employees are Horner syndrome, which is my Meto Andros. So the people will be constricted, the eyelid will be drooping and the eye won't be producing any moisture. This is seen in um a pancreas tumor which is a respiratory, it is a cancer of the lungs effectively. And then you also look at the um conjunctiva. Let's so you ask patients if it's OK to pull down the eyelids and you effectively just do this and look in the red space for any polyp uh with the patient, it's best that you do it than the patient doing it because they can get confused, doing it. So it's better you do it yourself and then from here, you'll move on to their mouth, ask the patient to open their mouth wide and look inside and look for a few things like central cyanosis. You look for any blueness, any change in color candidiasis, which is the tongue will be whitened and it's, it's oral thrush. It's caused by um overuse of corticosteroids normally from inhalers and also dehydration. So these are a few of the signs that you can see. It's like a Chondro pallor. It looks slightly whiter than normal. Um This is a nice diagram of, of Horner syndrome, which you will actually, it will come up 3rd and 3rd year, but this is what it looks like. It's relatively common as well. Um And then also the bottom left is not a very nice image, but oral candidiasis, it's just whitening, it's, it's all thrush. And then from here you then move on to the neck. Like I say, you keep moving down. Uh Once again, tell the patient, I'm now going to move on to look at, have a look at your neck. The first thing you do is you check for the hepatojugular reflex, which um is the the arising J DP. So you ask the patient to look to the left and look upwards. So while they're lying at 40 100 angle, ask them to look um left and up and while they're doing that, you press just on the, on the left side of the patient's uh the right side of the patient's body, the side closest to you, you press inwards and if the J BP rises, um well, that, and that's a positive hepatojugular reflex. Um Also when you do this before you do it, ask a patient if they have any pain in the area, if they have pain, don't do it, it will hurt them. Um Then from here you move onto the neck itself and there are a couple of things that you do in the neck for a respiratory exam. And the first is is to feel to the position of the trachea, which is with the on the SCE notch. You put, you use your three fingers place the 2nd and 4th, either side like that and use a middle finger to poke in and feel whether the trachea is centered, it can be pushed to either side by certain uh by certain respiratory pathologies such as a pneumo tension, pneumo thorax and push it away and a a collapsed lung will pull it towards the side of the lesion. Um The next thing you do then feel the crico tunnel distance, which is similarly the same three fingers, put your, put your fourth finger on the super notch and do that and feel for the distance. It should be around three fingers. If it's reduced, it signals hyperinflation, which is something that you find often in CO PD. And then the next thing you do is then you palpate all the lymph nodes in the head and the neck. So you start, you do submental submandibular uh preauricular postauricular occipital, um posterior cervical, anterior, superior, anterior cervical chain and inferior. Uh and while they're doing the palpation of the lymph nodes, make sure that the movement never lift your things off. The patient, keep moving along and effectively prod them like this. So that movement and you just feel all around. Yeah. So yeah, this is this a tral deviation, like I said, use three fingers, use a middle finger to feel that it feel that it's just centered. Um And this middle image is what it looks like when you do the patho juggling reflex to look for a raised J BP. Um And there's a lot right? The diagram of uh some of the lymph nodes found in the head and neck. So f from here, then you move on to the chest and you start doing the exam. So like I said earlier, I do a closer inspection straight after the general inspection. Some people choose to do it about now find what works for you when you're practicing. Some people, a lot of people prefer to do it now like just the final works for you. So from here then move on to looking at the apex beat. This is similar, you do the same thing for the cardio exam. You repeat it in this um similar thing with the f the first time you're feeling for the chest, always make a show of it. Use find the external angle, find the second I CS and count downwards to the fifth space, make it very obvious and it's in the midclavicular line. So it's down here, uh use the pads of your fingers like this and like the image actually feel along the line, move left and right and try finding, see if you can feel it. There's a good chance that you won't be able to feel it and that's perfectly fine. If you can't feel it, don't lie about it because they do check the patient beforehand. They will nurture lying. So don't lie. There's no point in lying. There's nothing wrong in not being able to feel it from here. You then move on to the chest expansion. So the chest expansion is the first proper step of the respiratory exam. Once again, inform the patient. Now, I'm going to put my hands around her chest and have a feel what you do is you use your hand like that and like the image, you place it around the patient's rib cage from here. You're gonna ask them to take a deep breath in and a deep breath out and you feel for the chest expanding and it'll expand like that. Normally your fingers will move apart. It should be around four, between four and seven centimeters, your finger should rise, it should move apart around five is quite normal. Do this a couple of times, say, say, say take a deep breath in and then out and in and out do it a couple of times. Make sure to compare both the left and the right side cos some pathologies can cause there to be an uneven uh rise during chest expansion. So look at, look at it from both sides. Uh This is a video I have hopefully it was. So this is a video of just chest chest expansion. This is what it looks like in a patient. And the next step from here is then the chest percussion. This is where you tap on the patient. Tell the patient. Now I'm gonna have a tap of the chest and I'm sure you've been taught it before, but in case you don't remember, you use the middle finger and you tap like that, you tap on the middle finger. I've been taught that if you do that rather than hitting, if you let your wrist swing, you tend to get a better sound out of it, you should tap in four separate positions and the four that I so you have to do the supracollicular fossa and the line. These two are necessary. The two in the middle are not as you, it's not specific ones you have to do, but I recommend doing supracollicular fossa 24 and six in the line. Um Once again, like earlier with the apex beat have a feel for it. Find the second space, find, find certain angle, then find the second space countdown, make it very, very obvious they like to see that. So like I said, go super fossa 24 and then in the mexi line, go for the sixth intercostal space when you are doing it, when you're tapping compare like for like so tap one side, the next side, one side, the other side and try and listen out for any differences in sound. It might be that one side is dull or more resonant or something like that. Um So these are a few causes of different of dullness and hyperresonance. So dullness is generally caused by something being there. So something like a collapse or collapses rather a the lung collapsing, but consolidation, fibrosis, pleural thickening and a pleural effusion which is specifically ster dull. These cause dull vester percussion and then hyperresonance are 10 to pneumothorax and hyperinflation, which as I mentioned earlier is caused by CO PD. Interestingly, I've had doctors previously. Hyper residence is a lot harder to hear. It's hard to hear an increase in residence, but it, it is not that hard to hear a reduction in residents. So odds are the patient won't have any pathology. Once again, don't lie about anything. If you can't hear something, can't hear a difference. Don't mention it just if they seem similar, they are similar le let's do that. Um From here you move on to chest auscultation, which is having a listen with your stethoscope. Tell the patient now, I'm going to have a listen to your chest. Once again, I recommend using the same positions of a supraclavicular fossa, 2nd, 4th and then sixth mi in the middle of the re line. Um like percussion. You compare each side, compare it light for light, go do it like this and compare the sound on either side. So every time the stethoscope touches them, tell the patient to take a deep breath in and deep breath out. I recommend saying, yeah, each time you touch just so that they can remember, sometimes they can forget to just say. So the ST ST stethoscope goes on and say, take a deep breath in for me and a deep breath out and just have a listen. But um inspiration and exploration. Um when you use a stethoscope, you use the diaphragm for everything on the chest except for the supraclavicular fossa, which you use the bell for when you're doing this, switch it and have a listen to make sure you're using the correct side. Um The main two types of breathing sounds you can hear are vesicular breathing and bronchial breathing. Vesicular breathing is normal. It sounds like rusting leaves and it's the sound that you would expect to hear in the patients that you will get. Or patients you see bronchial breathing is found in pathologies like ization or pleural effusion. What you hear is a higher pitch blowing, which isn't normal um, it's unlikely it'll come up in your off the exam. But when you're on the wards, I recommend finding patients who have these abnormal sounds so that, you know what they sound like in a real patient. It's a good thing to have. Even if it doesn't come up, it's really beneficial to know what it sounds like. Um, and a diminished breath sounds is of course a reduction in breath sounds, absence of breath sounds, which can be caused by things like a PPL pleural effusion or bronchial obstruction. And then from here, you then do everything you've done on the front, your piece on the back because um because there's a mirror in the back. So from here, tell the patient to to sit up because like I said, the patients at rest, they're at a 45 degree angle in examination, ask them to sit up, sit up straight, potentially even put across their arms. And then you look at the back and repeat everything you've done again, repeat the chest expansion, repeat the percussion and the percussion. You can do three spots, just find two on the back and then the ex again. Um So do that with percussion, do auscultation on their back. Same thing compare like for like compare side by side, look for any different here and look for any differences. And a lot of the examinations which is where you just press in the lower back like it is on this image you press and you feel thin fluid from here, you then move on to the legs. Wait, uh it's palpation of the legs. This is something that again is common in all of the exams. Tell the patient I'm now going to have a quick look and feel of your legs. And you first ask them, have they felt any pain? Cos they might have felt pain, something like a DVT can cause pain in the leg beforehand. Squeeze their calves when you check for a DVT. So just give it along the leg, just squeeze like that upwards. Ask them if they have any pain and also look at their face cos they might not say anything, but you can see in them wincing if they're in any pain. And then you also press their ankles to feel for edema. And there, there are two times for shot pitting edema and non pitting pitting edema is like an image where you press in, you pull your finger away and it will leave an indentation of your finger. And this can be caused by heart failure. And a non edema is you push inwards, you can feel it's, there's fluid there but it will not the impression won't remain. And then the last set or the last step of the exam itself is your conclusion. Um This is something that you get with is common between all the exams and you should just nail it. It's really something you should just practice again and again and it becomes easy to nail. Say to the patient, thank the patient perfectly. Say, thank you for letting me perform an exam on you today. Just tell them they can get dressed and ask them if they need any help like you did at the start, wash your hands again. Always wash your hands before or after. If the opportunity comes up, wash your hands, nothing wrong with it. And then um after this, you don't tell the patient and you say this might not necessarily be straight after the conclusion, it might be after your presentation either way. But you will then need to say a few things you do after this examination. And the way I was taught was to split it up into bedside tests, imaging and further exams. So you'd say to complete my examination, I'll take basic observations such as O2 sats for imaging, I do a chest X ray and for further exams, I do a cardiovascular exam. Just find a few things for each exam that you know, you'd want to do, learn it. And then because the question will come up. So it's, it's a good one to just have something learned beforehand. And then after you've done the examination, you need to present it to the examiner. When you're doing this, mention everything that you see mention whether it's positive or negative, positive signs are better because I mean, you're looking for something wrong when you're doing the exam, positive sign mean something is wrong. Mention it, it's better to mention positive signs at the start, say stuff that is that you notice that is wrong, it's unlikely that there will, there will necessarily be clergy. However, in a couple of my exams, there was something slightly wrong with the patient. And so it might come up that there is something unexpected in the exam. Um when you're going through stuff like the hands and the face mention a couple of things you're looking for. You don't need to list every single thing you look for but say, you know, there was no signs of tar staining, there was no signs of cyanosis, just mention it a couple of things. Uh Like I said before, don't lie. If you can't see if you can't feel the fex beats or you can't hear a difference in um percussion. Don't mention it. It is not worth, you know, don't lie about it. It's not worth lying about. Um be quick. Don't waffle, don't mention stuff that does not need to be mentioned. This should be under a minute long, so small details that don't really matter, just skip them and like I said, just practice it. This is something that with enough practice comes like second nature, you know what to include, you know, you know, what not to include. Um So this is an example that I've made. So today I per performed a respiratory exam. On a 22 year old male on general inspection, he looked comfortable and can't arrest with no medical paraphernalia of respiratory disease around the bed on close to inspection of the chest, there were no signs of scars or deformity. Examination of the hands, there were no signs of clubbing or tar sailing. The per per refill time was normal temperature was normal, pulse was 18 BPM and the respirate was 16 beats, uh uh breath for minute. There were no signs of Horner syndrome and central diagnosis or candidiasis in the patient's face or mouth. The trachea was centered and cryphalus was normal. His J BP was not raised and there was no lymph node enlargement. The chest expansion, percussion and auscultation were normal with normal breath sounds front and back and there was no sacral or pedal edema. And so overall, this was an unremarkable, unremarkable examination. Um So actually moving back, I did forget to mention one thing after um auscultation, you also do the vocal rema, which is a similar thing to auscultation. But instead of taking a deep breath in and out, you repeat the process but do it with them saying 99 each time the stethoscope touches them, listen out for any difference in, you know, volume or pitch. If the odds are once again, there won't be any difference, but you need to do it. So same thing in the same position, supraclavicular phosphor 24 and then six in, in the middle maxillary line. Um Every time there's a touch it then say, can you ask the patient to say, can you say 99 for me? Um Same thing with auscultation, use a bell for the supra fossa and the diaphragm for everything else along the chest. OK. So now I'm gonna move on to X ray interpretation. So at the end of your respiratory exam, there will always be a question on the X ray interpretation. It'll always come up because it's one of the easiest things that they can ask you. And it's something that you should be able to read. Even if you can't recognize the pathology itself, there are a lot of marks you can gain just from reading the image and reading the x-ray itself. You don't need to know what you're looking at. So when you're doing it, comment on every single little thing you can see on a normal x-ray, it'll say loads of details like the patient's name, date of birth, hospital number, the date the X ray was taken and the direction whether it's ap or pa if you see these things on the x-ray mention them, they will, they are, they are generally all worth a mark each. If you don't mention them, you will lose marks. They are such easy marks to gain because the information's already on the screen for you. Um So just look all around the image, look for, just look at the image, you don't need to answer instantly when they they'll give you an X ray and say interpret this for me. Take 30 seconds, look at the image, read it, look at every single thing and any information you can see on the screen. Tell them, oh sorry on the image, tell them. Um And when you're doing this, after you mention all the very obvious things like the patient's name or the date it's taken on, you move on to right, which is a basic structure you should learn for interpreting x-rays. This is to look at this is right is regarding to the quality of the image uh the quality of the X ray. Um So the R stands for rotation, which is whether the image is centered or the patient is rotated slightly. And you look at this by you look at the center of the center and then you look at their um clavicle see if there's the same distance between the center and the end of the clavicle on either side of the patient. If a distance is shorter, if one side is shorter than the other, it means the patient is most likely I rotated that way. So if you see if this side is longer than this side, on the patient is turned like this slightly, which makes it a bit shorter if you see this mention it, even if you, even if it's the same on both sides mention it say the patient is not rotated. Um you then go into inspiration. So you look at whether the amount of ribs you can see on the image. So you can see anterior and posterior ribs, anterior should be between five and six ribs and posterior 10. Count them out, count them out on both sides and make sure it's the same number on both sides. And if there are more than expected, say the patient's inspired more than you expected, say, if there's uh less than expected, mention, it just say what you see. The next thing is a penetration, which is the penetration of the X rays themselves. And you notice this by looking at, you can look at the heart and also the um vertebral bodies of the vertebra, look at the best is for the vertebra, look at the shape of them if you can see them clearly marketed and you can see individual processes at the individual vertebra. It's odd that it's got a good er level penetration. If it blows into one, like a one white strip, one area or it's difficult to um tell the heart and the um vertebra apart, then the penetration is quite poor. And then the last thing is to like the exposure. Um and that is how much of the chest effect that you can see. So you should be able to see slightly below the diaphragm and above the clavicle. You should see these things because things like air in the diaphragm is something that you, you look out for when you're looking at a chest X ray. And similarly, the trachea is necessary in a just sex ray to look for for these like attention pneum or thorax. So like I said, if you look at, if you look out for all of these things, mention them, so whether it it's normal or weird mention them and you'll gain marks for it. They are such easy marks to gain you can get even if you don't get the pathology that they are displaying. If you mention everything that you see, you can get almost full marks. In fact, in my exam, I got the pathology wrong, but I still got full marks on my respiratory exam. Um So this is an example of an X ray. So like I said, mention every single thing you see and another framework is ABCD E to look out for. So look at the airways, start with the trachea see whether it's centered you can see, I mean on this image it's slightly cut off. But um I don't know if you can see what I'm seeing here. No, no. Yeah, this is this part here is the trick here. If it's pushed either way. Like I said earlier, there are a few patho I can call it look out for this. So tension pneumothorax often typically pushes it away from the side of the lesion. So and then collapsed lung will draw it towards the side of the lesion. So look out for the tracheal deviation. Look out for the Bronchia. You can often see them in this image. I'm not entirely sure if you can see them, but sometimes you can see them left and right, the right. So see it on the left side. So look out for them if you can see them, mention it, say they look normal, say the trachea centered and how the structure of the, well, which apparently are in this image. They are the small circles. These are very, very hard to see, to be honest with you. Um from A then go to B which is breathing, look at the lungs, look at the size of the lungs, whether they look normal, whether the whether the pleura of the lungs are normal, there should be a sharp clas angle on the corner here. This is the a sharp csph angle which should be sharp and it can be affected in things like like a pleural effusion or um a puncture. Um Then we move on to the heart, look at the heart. Um the heart should occupy around 50% of the space here. If it's higher or lower, that's abnormal. And mention it similarly mention whether anything is going on to it like a tumor or mention the shape of it if it's on the or even something like on the wrong side. Um One thing to note is that regardless of whether A X ray is front to back or back to front, the heart will always be on the same side, on the right side of your image uh on the right side of your image because they always tip it to make it patient's left is on your right every single time. Um And you look at the diaphragm. So the diaphragm is here at the bottom and you see the hemi hemi diaphragms refers to each half of it. It's possible that one side is raised, one side is flattened into some paco. Um look up, look for the shape. So in a um normally it should be curved. If there is hyperinflation like in Co PD, this can be flattened. Um Also look for air under the space. If there's air underneath the diaphragm, it'll be black, co air shows up as black black underneath. It should, it should look, look, I guess in a normal patient. Um And then the last thing is it everything else you look for bones, the ribs were broken, soft tissues. If there is maybe a feeding tube down the patient, um pacemakers, you can often see pacemakers in the corner. There will be a little electrical little machine up here with some wire sticking out of it. So literally, if you see something on the image, just talk about it, mention it because you'll gain marks, you're not gonna lose any marks, you can get them slightly wrong you're gonna lose marks by doing that. Um So yeah, once again, these are um like I mentioned before. So with the, these are the things to look out for. So you look at lung fields, um extra air, look for fluid. I've got an image later on showing what a pleural effusion looks like as well as well as pneumothorax. I have a couple of pathologies look for consolidation. Um And then, so you see, so the heart should be less than 50% of the thorax on APA film. Um Look at, look at where it is, what shape it is. Um Yeah, so this is an extra pathology. And if you could, could you guys put on to the mentee, what you think this pathology is and if possible, also potentially mention some of the things that you can see on the image that might convince you as to what it is. I'll give you a me or so for that. Uh If anyone hasn't got the me the men code, it's on the chat here. It's 7980116, it'd be, it would be great if I get a get a couple of responses, I've got, I've only got one so far. Just even if it's wrong, it's fine. Just tell me what you think it is. The point of this is to see what you know, if you get a great right. That's great. If not just learn from what I tell you pretty much. OK. So now I'll just go over the pathologies uh the, the pathology that I see in this image. Um So this is a left sided tension you thorax. So uh on the left, left side is this is the patient's left side and you can tell something is wrong because it looks much blacker than normal. You can't see any of the imperfection you see here, nothing is seen here and the diaphragm as well. The look at the diaphragm, uh the shape is completely different. So going through the A B ABCD E look just firstly, the telltale sign for attention to your thorax is a trachea. You look at the trachea here, it's pushed away, it is curving this way like that, which is not normal. Normally, it should go downward like this. So attention to your thorax, it gets pushed away from the side of the lesion. Um then the lung is very black, which means there is more air than normal. That is, you can tell if you compare both sides. Like I said, there's a bit of whiteness a bit whis here nothing over here. It's completely black, which means there's way more air than you normally expect in the lung. And then like I said, the D is the diaphragm, it curves downwards, it's flattened, a flattening of the diaphragm. There is more air than normal, more air than expected in the lung. And then also e is the media sign, it's slightly harder to see. But the basically all of this stuff here is slightly pushed aside. It's hard to notice you might not see it, don't worry about not mentioning it. Um Here is the next pathology. Once again, please just type down what you think that this could be. Um this one you might have seen before, I think it is slightly more common for you. So, so this is CO PD. It's uh the path pathology you've come across probably quite a lot by now, by third year, it's quite obvious to see. So similarly, go through the ABCD approach, the airways aren't really affected that much in um CO PD. But you go to B which is the lungs and the lungs are hyperinflated. And you can tell this because if you count the number of anterior ribs, which are these, these are anterior ribs, there are I think eight visible on this image, a normal image or normal X ray for a normal patient should be between five and six that are visible. So there's more than expected. Um And then you also just see the weirder shape than normal, which is what the D mentioned. The diaphragm in hyperinflation, there is more air than normal in the lungs and it's bilateral. So unlike a pneumothorax, but only one side was flattened on the diaphragm in CO PD, both sides are equally flattened, it across both. And so which is why the diaphragm is uh flat, it's filled, the image is getting blacker as well cos there's more air than normal and this is called Barrel Chest where it's, I mean, with how like well filled out the lungs, see in this image it is called B er, Barrel Chest. It's CC APD. It's a common pathology that might, could quite easily come up in your exam. And then there's another pathology which once again, uh I'd love it if you guys could just, you know, it'll take you 20 seconds, write down an answer. Um I'll give you another 30 seconds or so for this. OK. Yeah. OK. So I've got one answer and that's the answer is right. It's metastasis, specifically cannonball cysts. Um If you ever see this sign, even if you don't, can't tell specifically what it is, you should be able to, after knowing this, you should be able to now tell what it is. But even if you can't just mention it, mention the fact there are, there are lots of c circular opacities found across both lung fields, bilateral across the entire lung fields. Um And the concentration increases towards the bases, canal metastasis is as expected a type of cancer. Um And like just mention anything, you see mention the fact that there are multiple motor slides mention it's bilateral mention, it's across the entire long field. Um So, yeah, just describing that as diffuse round capacity which are present bilaterally across all long fields And then this is the last pathology I've got here. Uh Once again, it would be great if you guys could just write down what you think it is. So, all these pathologies are things that might come up because they are, I guess they're easy to, to test because they're generally quite ob once you learn them, they're quite obvious. Um And also I'd recommend just after this lecture or just towards your osk, find images of different pathologies, the more common ones and just learn what you're looking for. Because when it comes up, it is so easy to tell once you know what you're looking at. And so the person who wrote in the mentees, right? For all the fusion and so go the A to e er framework, um A pleural effusion causes deviation of trachea. So once again, looking down the center here, this, you see the trachea, it's pushed slightly away. Normally you'd see it, it would go. This image is slightly to, the image is slightly angled. But if you, if you follow the, the uh spine, the trachea slightly pushed that way cos this here is a MP effusion. It's quite a big pleural effusion and then the b the breathing look for air. Air, like I said is black, this is all air, this white stuff is not air, you cannot see past this, you can see air above but not in it, which suggests that it's a pleural effusion similar diaphragm, you can't really see it here at all. But in an effusion, it would be flattened normally. And here this bit here is the air fluid level, which is where the pleural effusion ends. And these are quite obvious to, they are quite obvious images because you'll see a mall area white. Why can't I see my mouse? You'll see a mall area white and a little curve here. That's a pleural effusion. And so when you're telling the examiner, what you see, also, remember to mention the side, don't just say there is fluid, there is ap say it is a right sided pleural effusion uh mention the sides because there are obviously to the sides and they want you to be able to tell the difference because some people it can be easy to, if you don't know enough about chest X rays to mix up left and right. But most chest, chest, chest x rays will have like here, they'll tell you left and right part. So now I've got a few SBA S um about respiratory pathologies. Once again, use the mentee, I'd like to see a couple of answers. It's nice that one of you keeps the answering. I'd like if a few more of you would answer to. Um So I'll give you about a minute or 30 seconds or so, just to give a couple of answers, I did mention this earlier. So if you were listening, you would have, you should hopefully know, uh, the me, I will just type the men code in again. It is. Mhm. It's, yeah, it's 7980116. I put in the chart here as well. Cos I've got a few more answers down than normal, which is great to see. And so yeah, like I mentioned earlier, these are a few that you'd, there are, these are a few causes of clubbing. Um, so there's things like bronchial carcinoma, cancers, bronchiectasis and fever, fibrosing, oitis, mesothelioma, and lung abscesses. Um You will be asked a couple of questions regarding pathology in your, at the end of your respiratory station. So there is a massive document someone's made on the um note bank use it. There are loads of answers, just learn all these things. You might forget them 10 minutes afterwards, but learn all of them, they can come up and if you get them, they are such simple marks to get. And this is the next SDA. Once again, I'll give you 30 seconds or a minute. I'll just read through it. So Miss Knight is a 45 year old man who, sorry, 40 year old woman who presents the A&E with chest pain and shortness of breath on percussion of the chest. You hear a dull note across the middle and lower lobes of the left lung. He's got reduced vocal resonance. What do they most likely have? So, put down your thoughts as to what you think they'd most likely have. Ok. So lovely. But one of you has got it, it's a pleural effusion. Uh So if you hear, if you yeah, dull notes across one thigh, middle and lower suggest that it's fluid cos it's not across the entire lung field. It's just middle and lower. It's unilateral and it's dull. So this is most likely a pleural effusion. And so the symptoms are shortness of breath, sharp, chest pain, reduced percussion, as mentioned and also reduced focal resonance as well. Um And there is a reduction in percussion and vocal residence because the build up of fluid doesn't transmit sound as well as air does. And then this is the final uh sda. So could you name two types of medical scars you might see on the anterior chest of a patient? Ok. So as I mentioned earlier in the powerpoint, these are a few things that you might see on the front of a patient's chest. So midline csom, which on there, anterolateral ey, similarly in the center, the clamshell incision, which is sort of clamshell shaped like this in the chest. And also you might find those chest drain incisions. So now I'm gonna move on to history taking, which is a separate station to the respiratory osc exam, but like the respiratory exam, it'll definitely come up. You get, I think three histories and respiratory is one of the main ones that it it'll always come up. So you take a full respiratory history of a patient. Um The station is, I believe, 12 minutes long with 10 minutes to take the history, one minute to present to the examiner what you think the pathology is and then one minute to answer the questions. And so the overview, I'm sure that most of you have done histories before it's like done in the past. You go through, you introduce yourself and you do the presenting complaint, the history of the presenting complaint, a systems review. You do the path medical history, drug history, family, history, social history, and then you do, I you summarize and you do closure. So it at the scene. So Louisa has been rushed to the emergency department as she started to feel short of breath two hours ago. Once again, think of a couple of things that you think of the things that you need to ask her and put them down onto the mentee. Ok? So the of course, the first thing you do is your introduction. Um, so say hi, my name is Aldo Pr and I'm 1/4 year medical student. Er, your doctor's asked me to have a quick chat with you about why you've come to them today. Start off by asking for the name and the date of birth crucial for all exams. Anything you do in the hospital name and date of birth to make sure you've got the right patient. So please go to start by asking what your name and date of birth is after this, when it comes to history, taking the crucial thing to mention, is it confidentiality? You have to tell them that everything you say or they say will remain confidential between you the patient and then also the medi medical team that's taking care of them, don't just say it's between you and the patient because the medical team will also hear everything you said similarly tell them because if they don't realize it's confidential, they will hold in details that might be necessary. And then once again, then after you say you'll see your GP as normal after this, so that they know that they will, then by having talked to you, they'll get the consultation that they came in to see and then make sure that they get the consent to make sure that they're ok with this. Does this sound ok to you? Um So you start with the presenting complaint. Uh The first thing you do is ask them, you just tell me in your own words, why you've come in today and you give them a minute to answer, they'll probably aren't start with something, you know, my chest hurts something like that after this and say, what do you mean by this? And then give them a minute to explain cos the exam, the active will be given a brief that only when you say, um you know, explain your own words that will, they will start talking about it and they'll mention a lot of the detail when they do this. Um So give them a minute when they are speaking in the first minute or ge generally when they're speaking, don't interrupt them, but especially in the first minute, don't interrupt, let them say everything they have to say. And if they stop to say any more details that you would like to add, always do that cos that's a massive mark, they'll admit it. Um Then you then go over the history of the presenting complaints. So when did this start ask them when it first appeared? Has it happened before? Is, so this is the first time this has occurred, has it happened in the past? Is it something you're used to, have you noticed anything that makes it causes it to come on? So activity or coughing? Um Have you noticed anything that makes it better? Medications and then, you know, to sos, which is a framework, I'm sure you've heard of and I'll move on to the next slide and also flaws, which is the red flags for cancer symptoms, which are, um, fatigue and fever, lethargy, loss of appetite, weight loss, and night sweats. And if they've got a cough, ask them about the character of the cough. So, is it dry? Is it wet? Is it chesty? The sputum come out? What color of the sputum? How much sputum is there? Blood? How much blood is there? Pain when you cough. So this is the Socrates, I'm sure as you've done before, it's the site, ask them go down this framework because when you're doing it in the exam, even though you probably know all the questions, it can be quite easy to slip up and have a lapse in memory where you just forget what you're doing. So having the framework that actually really, really useful, even though it might not seem like it outside of the exam. So go through it, ask them where the pain is to ask them to just point it out where in the chest it is. When did it start? Um, describe it? So, is it sharp, is it blunt, is it crushing? Does it move anywhere? Radiation? Does it move anywhere? Does it go upwards downwards to the back? Is there any symptoms alongside it? So, do you get nausea? Do you get vomiting cough? How long has it been going on for? Is it the first time it's happened? Uh, is it stopping in between? Is there anything e exacerbation factors? Does anything make it worse? Does exercise or sitting up make it worse? And also does anything make it better? Just taking any specific medication or lying down or sitting in this in a specific way, make it better. And finally, the severity which is treat the patient on a scale of 1 to 10 with one being normal, no pain and 10 being the worst pain you ever felt what it, what it is? So this is what the patient then says to you. So she had the breathlessness started while she was taking part in a gym class and has continued for the last two hours. She feels breathless all the time, but it's worse if she moves or tries to do exercise. She's never had anything like this before. She does not have a cough or a fever or a wheeze. She's not cough up any blood and has not lost consciousness. And then going down this framework, the pain on the left side of her chest, it suddenly started two hours ago and hasn't stopped since then. It is sharp and stabbing in nature. It ra it does not raise anywhere. She's breathless and she feels dizzy. If she stands up, it's been constant since, since the onset. Uh it's made worse and she takes a deep breath in and also exerts herself. And the pain is best when she sat down on the bed and takes shallow breaths. She's tried taking paracetamol, but she's found this hasn't helped. And on a scale of 1 to 10, it's an eight in terms of pain from, hey, then do the systems review, which is effectively where you go through the patient and you ask them head to toe about symptoms in that generally, it should be symptoms that relate to respiratory pathology in each uh in each system of the body. So like, yeah, you, your eyes? Have you seen any change in vision? Do you wear glasses, ears, nose, throat and you've got a cough? But you're not see blocked noses and your nasal drip. Uh cardiovascular, any uh palpitations, chest pain, any edema around the heart, any fluid, any shortness of breath, um, respiratory, this is a respiratory illness. So those questions should be done beforehand. Anyway, gi notice any diarrhea or constipation or M sk muscular weakness. If you notice any pain in the joints, skin, any rashes, any bumps, any pustules. So this should take about a minute, just go from head to toe, think of a couple of things in each system that you'd ask the patient try and relate it to something that could be seen in respiratory pathology as well. Yes. So it's a rapid fire questions. Just it's a quick run through just to look out for any symptoms that you they may not have answered, said you might have missed an asking. So she said she's got a headache and she feels nauseous, but she thinks that it's due to jet lag because she's just come back from holiday. Um She also has pain in her left leg which so this is similarly awesome about um when it comes to chest pain, asking about pain in the legs is quite a big thing to ask about because it, it is related to certain pathologies. Um CeleXA here, her leg is swollen, it looks red and it's painful to touch, but she thinks it's bruised and does not think it's relevant from here. You move on to the past medical history and sign and person to the patients. Say now I'm going to ask some questions related to your health in the past. So has this happened before? So ask another, has this happened anything like anything like this has happened in the past? Uh do they have any long term health conditions? And list some examples such as diabetes, high BP, migraines use simple terms like high BP rather than hypertension because they probably won't know what hypertension is. Um, ask them if they've been to hospital at all in the past for anything, ask them if they've had any surgeries. Uh And also also if you go any me take any medications and if they are asked to note down which ones they are, how often they take them, what doses they are, um, why they take them? And then also a big question is about the drug history. Ask them if they have any known drug allergies, ask them so often it'll be antibiotics, that sort of thing. Ask them if any and if they do have an allergy to drugs, ask them what the symptoms they experience are as well. So the patient does not have any long term medical conditions. She only visits her GP for a prescription for a combined oral con concept. A pill which is regone she's not had any surgeries and she's never been admitted to the hospital. She takes the, uh, concept a pill and has done so for the last three years. And she also takes a multivitamin that she buys at the local supermarket with her drug allergies. So she is allergic to penicillin. And the last time she took it, she had a skin rash and was told to avoid it in the future. Um, there's some actually drug allergies do come up decently often in Aussies. So always ask about drug history and also even allergies in general. It's not that important to know if they've got an allergy to whatever strawberries, but it's not, it does not harm you to ask them. And then from here you go on to family history and signpost it again. Now I'm going to ask you some questions about your family and then ask them about start with respiratory illnesses. Does anyone in your family have any respiratory diseases like asthma or CO PD? And then from here move on to wider health conditions like diabetes or cancer or hypertension. Um And then suddenly ask them about their parents, ask them, their parents are alive and if they're dead, what it was that caused them to die because if it's something like CO PD asthma, that sort of thing, it could be quite relevant to the patient. So the patient answered saying that both of her mother and sister have asthma and eczema which are both well controlled and her father has high cholesterol. Now, this is the bulk of the history, which is social history. Um, once again, signpost it. So now I'm going to ask you some questions about your social history. Start with smoking and drinking. Do you smoke at all? If they say yes, ask them how many years and how many cigarettes they smoke per day? If a patient says I've quit, ask them what they mean. So when did they quit? Cos it's really common for patients who have recently quit a month ago or even a week ago to say I've quit, I've stopped smoking. Um, if they have asked them when and the thing is even if they stopped smoking, the effects of smoking are of course long term. So ask them when they stopped and calculated it, you need to be able to, to calculate the pack years, which is the packs per day times by the number of years that they smoked for 20 cigarettes is one pack. So if they say I smoke 10 cigarettes a day, that's half a pack. Um, so from here move on to drinking. So ask them if they drink and how much is, how much they drink in a normal week? When you ask this, they might say a drink. Ask them what they mean by a drink. Is it a shot of vodka? Is it a glass of wine? How much of it? And how many of them do they have? How often? Um And then you should learn the units, I'm not going to thin them now, but learn what, how many units are a normal ca you know, ca pint of beer or a glass of wine. Generally, one unit is one unit means 10 M of pure alcohol. And it, you can work out quite easily by multiplying the percentage um of the alcohol against the volume of alcohol. Um, from here on to drug use and sign posts say that this is a sensitive question. But I need to ask, remember this will remain confidential between us and the medical team. Do you use any recreational drugs? Pretty sure it's confidential if they say yes, ask them which ones they are, how long they've used them for how much they use and then move on to other aspects of the social life. Like, do they work if they do, what is it, ask them about stress? Cos stress is actually quite a common thing. They bring up in these, in these, er, histories, ask them if they, how they find their job where anything's changed recently. And then some, they ask about, not as important but ask them about the exercise and diet to inquire about it. See if they're fit, they're healthy and then also who's at home with you? Do you have, you know, are you, do you less important for young people? But stairs shortness of breath in the home, whether they can care for themselves, whether they can cook themselves if they have any pets, any recent pets, cos those could be causing allergies and also then any recent travels. So the patient says that she lives in a house with her parents and her younger sister and she's a receptionist. She only smokes occasionally but admits that she smokes around 10 per day for the past 10 years. So she's got a pack history of five years cos it, it is 10, which is half a, a packer times by so it's, it's nah 0.5 times by 10 which is five. She drinks alcohol at the weekend uh with her friends and she's no, the main drugs. Um, ask about travel. Travel is a big one. Just do it because in the case of this patient, she did travel on holiday with her sister and there's a long 20 hour journey in total. Um The patient, the actor can withhold information if you don't ask specific questions like this. So ask about stuff. Um And then she, she's also had a pet for the past three years. So odds are what she has is not related to the pet because it's unlikely that she's now suddenly allergic. After three years, you don't write it off by asking me ideas, concerns and expectations. These are three very, very simple marks to get, you have to ask them. I'm sure by now it's drilled, drilled into you that you need to ask about ice, but just ask it and make it obvious. So say, do you have any ideas as to what could be causing this? Is there anything that's worrying you or concerning you in particular? And what would you like to get out of this consultation and let the patient answer each one? I know down? So the patient says that she thought it could be jet lag, but she's never had chest pain or breathlessness after a flight. She wonders if she's had a chest infection from the airplane and she was sat close to everyone else. She's worried that she might have stayed in the hospital overnight and she wants the doctor to reassure her that she'll be able to go home today. So when it comes to the conclusion, recap everything, so go from the start. The first thing they said for the last thing they said, go through it, step by step, tell the patient if I get anything wrong or I miss anything, point it out to me. Uh So because you might just forget it, it happens. So go step by step. Confirm with the patient. Everything you're saying is true and that you're not missing anything at the end if, ask them again. Do you think I'm missing anything? And also ask them if there's anything else that you'd like to add? Um cos they might still have something that they've not mentioned because you, you asked a question about it, but they'll still want to bring you to ask about it once everything's done. Thank them. Say, thank you for letting me take a history of you and I hope you feel better. I hope the doctor helps you. You'll see your doctor as normal after this and you have to finish it off by then presenting your history to the examiner. Um, relay all the key information that you, that you've been provided by the patient back to the examiner. If something seems very relevant, mention it, if something seems irrelevant, it's not that big of a deal to mention. So, an example for this patient is today, I took a respiratory history of a 25 year old woman. She presented with constant shortness of breath for the past two hours which came on during a gym class. She's never had anything like this before. There is no cough fever or wheeze. She had a constant chest pain for the two hours on the left side. It's a sharp stabbing pain that doesn't radiate anywhere. She feels dizzy when she stands up and the pain is made worse by breathing in or exertion and it's improved by sitting and taking shallow breaths. She found the paracetamol did not help and pain is eight out of 10. She has no long term health conditions and she's never been to the hospital and she takes regone ac OCP regularly. She's allergic to penicillin which causes a rash her mother and her sister both have asthma and she has a pack year history of five years. She drinks 12 years per week. And notably, she recently came back from a holiday abroad and has a leg pain since the leg is painful, red and swollen. She thinks it could be a chest infection from the plane and she's worried she'll have to stay in the hospital overnight and she wants to go home today to round off the, er, your, the history taking section. The examiner will then ask what are your top three differentials? Um Once again, it would be great if you guys are just go on the mentee, put down what you think the three. So you, you, you list them as your first one that you think most likely is and then you give two alternatives. Um, if you get the right er, differential, then you get, you, you gain more marks for it. But even if you mention other things that are wrong, if you've got a sort of justification for them, you still gain marks for it. So even if you're not sure say three things it'll gain you marks. Ok. So, uh pe is something that you'll probably come across a lot more in third year now. Um, and this is, this is the top differential because she had leg pain. It's a red swollen leg after a flight, which is a common reason, a common cause for a DVT and it's now led to a pe which is why she got chest pain, shortness of breath, pain on breathing and exertion. She got pe. So that's her top differential. And then secondary ones are spontaneous neora, which you think because she had sudden pain as unilateral was one sided and also pneumonia, unilateral and recent travel means she could have contracted an illness while overseas. And then you also need to give them further investigations that you think uh are, are necessary. So name three or four. So you do well scores for the DVT. You do a C CPA for the pe you do a chest X ray to get imaging, you do full basic obs to get the patients, you know, the patients basic stats, you do a breast exam and you also do an E CG. And so now just last thing is just a few tips for the um, history taking. Don't rush yourself if you get, if you forget stuff or get stuck, don't stress, you can always take a few seconds to think and breathe. It's better that you do everything right. And you know, don't say the wrong thing or rush yourself slow down. If you miss something, you can always move on, come back to it later. It's best to obviously keep a sign of framework, but it happens. It's better that you miss it. Now on ask it again at the end, then don't live at all. Uh If you're getting if you get stuck, do a recap. If you find yourself just lost in your own thoughts, just say, ok, just to recap. You've come with this, this, this and it's been caused by this, be empathetic. Um say you're sorry to hear bad news if they say, you know, my, my mother was going to say, I'm sorry to hear that and give them a few seconds afterwards. Um, breaks are fine. It's quite normal to have breaks. Don't feel the need to feel the silence, the silence is ok. And like I said, signpost everything between each of the segments because it looks good for the examiner. And it also tells the patient what's happening. And the last thing is that when you ask for the date of birth, um, ask them how old it makes them because in the exam, it's quite easy for them to say I was more than, you know, 975 and you just not in, you forget the date of birth. So you forget the age to say, how does this make you? And then you get to hear that number quite easily in your head. And so, yeah, that's it for me. Thank you for coming. Thank you for listening. Um I'd really appreciate it if you guys would confirm the feedback form that's been linked in the chat. I