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Okay. All right. Hello and welcome to this plaque to preparation session on examination skills will be part one. What promises to be a two part collector series essentially. Um earlier today was going through various examinations and I thought it was a bit much to try and cram minimal interference session decided to split, split it up. My name is Adrian. I'm an anesthetic strain E mails at York. Um and also you still graduate. So I did all of my training in the UK have been teaching various history, taking examination or ski skills over the years. So do you have reasonable experience with the process? So uh just very quick disclaimer. Um Again, this is part two session just being delivered by the crisis, rescue foundation and purpose and remit is not to provide guidance and matters relating to GM see registration that so please do address the GM see with any questions that you might have about their registration process. We can't really common or give any advice on that at all. Recommend resources. So again, I will keep referring back to the Samson hand handbook of Plateau and Clinical Assessment. It's a very, very good textbook, very comprehensive in terms of what you need to know the practical, which is the plaid to exam. Again, I cannot recommend geeky matics enough. It's a really fantastic free resource. Uh And they do have a sort of for clinical examination session more than sort of what I cover. In addition that if, if you have access to this book again, don't sort of feel the urge to go and buy it. If you can get hands on copy of essential Examination. It is really fantastic, very, very concise. It's it's proper against, but it goes through essentially everything you need to in terms of basic clinical examinations and findings and help to interpret them in terms of identifying pathologies. It's really, really musical book. Um terms of today in this session will go through some basic principles and introductions, set up to examinations, skills stations. We'll do a set today, like I said, we'll do another part as a second part as well to this lecture series. So today we'll concentrate on the cardiovascular respiratory abdominal and neuro exams and then a separate session we'll look at definitely um S K uh probably a thyroid and possibly a diabetic foot. But I I've yet to finalize that yet list. But do you keep, keep your eyes peeled because lecture will be confirmed in their future? So, very basic principles when you do examining examination skills. So it is all about structure. So something I will keep on referring back to regularly and a lot, it's all about having that structured approach. It's not about knowing everything. It's not about being able to identify everything and no everything in terms of picking up pathology. It's about having a good structure because coming into sort of um coming into like an F Turkel in job, which is what the plan prepares you for. It's really not about knowing everything. It's about doing an examination by yourself and being able to communicate the most salient findings to your seniors and then being able to discuss a management part with them. That's kind of the gist of it. So one structure that I would really like you to sort of take away today is sort of the look feel which might um include palpation and percussion and then listen or move and measure. So the look field, listen, measure kind of approach or or alternatively the look feel, move, measure approach. Um It's really important again, as we mentioned in, in the history taking session as well to set up properly. So when you go into a station or hands introduce yourself, always get permission from the patient to proceed with the examination. So don't assume it when we ask um in a examination skills station, you would say that you would expose patient as appropriate, right? So if you're doing the chest exam, then everything sort of technically above the waist should be removed, clothing. Why? So you can have a good look at the chest, you would reposition the patient as necessary. So we'll talk about, about positionings later on, particularly when we talk about the abdominal exam and always check with patient they're comfortable and if they're in any pain at all, so that's really important going in as well. So again, what you see here spelled out is Viper Qq and it's a very, very uniform approach to setting up that I would say most medical students in the U K teacher this way, um the offer a chaperone bit, um it's sort of a bit contentious as to when you do when you should or shouldn't as a blanket rule, if you want to be on the safe side, always offer it. But definitely if you're doing any sensitive examination, so anything involving genitalia or breasts or, or anything sort of private, you would definitely want to offer it. But you can do just to sort of take a box and be on the safe side. First is that we're going to go through is cardiovascular. So again, um we're going to start off with a general inspection. So this is the looking bit right when you go in and you've done your Viper Kooky, you've set up your ventral use yourself. It's always really important to pause and have a look from the patient. Look at the patient from, from the end of the bed, it's almost end of the bed. A gram as you will. Um And that's basically just to get a very quick overview and pick up on anything really, really obvious about the patient. Like if that's my nose, if they're very oversee short of breath, if they're pale, if they're flushed, if they've got stalking an email. So it's true. Excuse me, just be a very quick overview and equally while you're doing that, just look at any perf analogy around bedside, any medication equipment abilities, observation, Charles, just to get a little bit of a feel for the patient and what medical problems they might have. We then start the examination when we approach the patient from, from the hands and the arms. Okay. So we'll have a look at things like we'll have a look to see if you can find things like tar staining. So indicative of smoking. So you look at the nails and and the hands for, for, for that sort of yellow staining, the color of the hands, um any finger coming. So finger clubbing can be a sign for a whole number of different cardio respiratory diseases, including cancers, including um so um longstanding um culinary problems such as fibrosis. So basically, it's a whole list of things that it can be associated with nothing too specific but always worth looking for uh your spend to hemorrhages, jane relations. And also it's known as a sort of famously the ones that you would um look for in terms of your infective endocarditis, patient's I don't think I've ever seen them in real life, but it's something that you would always say that you look for an exam lives on the hand and arms. You then feel that the temperature of the hands of both sides have a feel of the hands and the arms generally have a feel of the pulse in the, in the radio pulse. You'd be feeling for rhythm and rape and then higher up the break your pulse, you would feel for William of character. And you can also do test at this point for collapsing pulps pulse, which would be a sign of atrial regurgitation. So it's basically feel the break your pulse live the arm quickly and see if that pulse disappears or not. And then in terms of your measurements, you will, you can do capitally refill time because it's very, very quick. You should technically do a heart rate measurement, but you can offer it up in the exam and see whether or not it's required and the BP in an exam, I would just offer it and they probably tell you to sort of move on that's fine. So then you can move onto the face, eyes, mouth and neck, and again, you start off by looking. So you look for that mail of flashing the cheeks. You look at corneal arcus and xanthelasma. So to, to indicate whether or not there's any dyslipidemia, the patient stuff is with contract pallor, which is a sign of any anemia, then central cyanosis, again, whether or not they're chronically hypoxic in the neck, you would feel for the quarantined pulse one at a time. So, no, not at the same time because that can be quite uncomfortable, but just one at a time. And again, you'd be sort of feeling to sort of see what, what the, the volume and the character of the pulse is like. And then in terms of measuring the JVP is, uh so the the drug dealer venous pressure would be something that you can measure in terms of centimeters above the sternal angle. So this is best on the patient sort of lying back about 45 degree angle, them turning their head to the woman side and you're looking at the JVP at a sort of perpendicular angle to the neck and then see whether or not it's very high up. Again, what I will say is in all of these examinations that you, you do, we will be for you, for your club, the size would be sort of stalking the obvious. So any any pathology would be pretty obvious like band or kind of pathology. So don't get too bogged down, basically do it and move on to it and move on. Any anything that would be obviously wrong with the patient would be very, very obvious, okay. Um with the move on to the chest, okay. So we've done arms, hands, arms, okay, mouth, face neck eyes and then we got onto the chest, okay. And, and this is this, I remember when I was first learning examinations, it kind of struck me as a bit weird that we sort of start with the hands and arms and we sort of work our way up to the chest, but it is very much the way that it is uh taught and the way that it is done. So now we get onto the chest again, look first, we're looking for any obvious pacemakers. So look obviously up here towards the left shoulder and then also he'll look for an I C D implant device, bit down the left hand side of the chest and then you'd also be looking for scars and in particular, really stand up to me scares to indicate previous heart, open heart surgery, open bypass, uh uh well, pure surgeries. Well, you'd be them feeling for the apex, be heaves and thrills. So heaves and thrills are essentially like palpable heart leads and sometimes palpable manners as well. And then you would get onto listening. So with your stethoscope, you would listen to the aortic pommery, try try to spit in mitral mitral areas, trying to identify any man's at all. Then you would go back, flip your stethoscope and listen to the eggs really and the current state as well for any bruise and bearing in mind that two maneuvers that you should try and do is to amplify uh mitral stenosis. So this is a few flip sort of ask your patient to turn on their left hand side and hold their breath in exploration that would amplify your mitral uh cirrhosis. And the chaotic river irritation can be amplified if you're uh patient to sit up and sort of lean forward so that you could hear it better if they then also ask them to hold their breath in exploration. Um Once you've done that, you can have a look on their backs. And once uh if it flows nicely, they'll be leaning forward at this point anyway, because you've just done that manu for aortic regurg. So you can have a little look at their back while, while you're there and just have a little feel whether or not they've got any edema at the sacrum. So that means that that would be indicated that they're very, very fluid overloaded. Um But equally also have a quick look at their ankles. So if, if you, if it looks like they might have a Dema just have a very quick feel of how far up that Adama tracks from sort of the ankles to, to to the sacrum. So I on intensive care, I was dealing with a patient the other day and actually, I can tell where his Adam ended because he was just so full of fluid that I think it sort of went up to the chest. So yeah, it can be quite expensive. But again, in your exams, probably not so much in real life. You, you might absolutely find quite significant overload and again, while you're looking, well, while you're, we've got the patient sort of leaning forward a bit, have a quick listen to their, to the base of the lungs. And again, really, it's not a full auscultation of the lungs is just again to listen, whether or not there is any crepitations that will suggest flowed overload. And then to conclude, you would say, you know, um you would say that in terms of further observations, you'd like to review their observations chart. So that would be heart rate, BP, temperature, capital refill and oxygen saturations is what goes typically in an observation tell. Um if the terms of further examination, you could offer up an abdominal examination and examination of the peripheral pulses and investigations. You'd like to request an E C G chest X ray echo and urine dip. And typically, if you summarize any findings and you conclude with these are further steps, I would like to take observation to further examinations and investigations, then that sort of rounds up your examination quite neatly. And then typically that's when the examiner would present you with questions along the lines of why are differential diagnoses? And in terms of investigations, how, how would they help you differentiate between those um those diagnoses? So that's cardiovascular exam, respiratory exam is a bit similar but also a bit different So probably these who are a bit annoying in that they they come across is very, very similar. But obviously, you have to bear in mind that the pathology that you're looking for is is different. So the respiratory exam is going to focus a lot more on the actual lung fields. But the setup again, requisition structure, it's going to be very, very similar. So you start with your hyper QQ, you come into the, once you come into the station and then you do that general inspection from the end of the bed, you're looking for clinical size or shortness of breath. And now think about obviously lung disease and lung pathology. So, accessory muscle use which you might see in patient sort of almost struggling to hold their chest cavity open. And also you often see it and sort of barrel chested nous typically associated with COPD hyperinflation, the passing of the lips as well. So that's essentially trying to force the albee of my open. So a bit of that uh you can see sometimes that literally the narrowing of the lips as people as a patient is trying to force air out. But at the same time, spin open the lbl I um at the bedside things you'd be looking for would be a supplementary oxygen, be that in the form of facemask CPAP by pump uh venturi uh inhalers nebulizers. So you can anything to do with the respiratory disease, hands and arms. So again, we start, that's where we start. So again, in terms of looking, task draining sinus has been the clubbing tremor. Those would be the main things to look through tremor, especially associated when you can get a salbutamol flap. So quite sort of a fine tremor in the hands. Um, feeling most. You'd again want to have a quick feel of temperature of the hands and have a quick feel the, the radio pulsing rhythm you don't have to bother about. And as opposed to the cardiovascular exam here, you don't have to bother with the break your polls and collapsing poles because really, that's not the focus for respiratory exam. And in terms of measurements, um couple of re refill time and then offer apart rate and BP, again, moving up again, we get to the face, eyes, mouth neck. So in the face, what you would be looking for is any Cushingoid features that can be quite common from uh in people who are on long term steroid use. Um So people with asthma or COPD um conjunctival pallor. So again, if there shortness of breath is actually um exacerbated by, for example, underlying Amenia and again, central cyanosis. So you will see that again, with chronic hypoxic patient's, you like seeing that you would feel for the carotid pulse. Uh and importantly, in the respiratory exam, also the trickier. So you would want to have a feel whether or not it's central and sort of warn a patient that you're going to pop. The, your two fingers typically is the second and the fourth finger on just the heads of the clavicles and then put your middle finger into, onto their tricky and just warn them that it's a bit uncomfortable. And then you would also want to have a quick feel for lymph nodes or any in welsh lymph nodes around the neck or at the base of the school or sort of round around the back of the neck. Again, typically in exams, I would have offered it up to the examiner. They said, don't worry about it, just kept moving on. So they typically, and in examining actually to do it, but definitely a good, good idea, I think to do it in practice because again, just being aware if there is any lymph node enlargement can be quite helpful in having a differential list. And then again, JVP, have a quick look because it can be elevated in respiratory respiratory disease as well. Then we come on to the chair. So again, as you can see, we've spent a bit of time looking at hands, arms, neck face. Um and so for around the eyes and then, well, like I say, don't get too bogged down. So I do try and get through those bits quite quickly because this is the crux of the exam, the chest and the back and the respiratory exam online. The cardio vascular one happens mostly on the back anyway, so the cardiovascular one you would mostly do in the front uh of the chest and the respiratory examine, well, mostly do it on the back of the chest. But before you get on to that again, look to look at for hyperinflation scars, especially things like lobectomy, two scars and also have a look for chest wall and spinal deformity. So you think about practice exc martin and practice coming not. And so that might impede a patient's ability to breathe, for example, and with any sort of spinal deformity, you think about your uh muscular dystrophies as well, where you, where you might have sort of a restricted type of uh lung disease. And that's what you would see on lung, pulmonary function testing as well when you go into feeling, have a feel of the chest expansion. So pop you two hands on either side of the of the or the sternum and as the patient to take a deep breath in and just make sure that the expansion sort of the rate at which your thumbs move away from each other is symmetrical, have a feel for the apex be because so that's really important in the restroom. For example, you wanna percussed across all the way, both sides on the back. So you always do the one side, do the other side, move down and do the one side, do the other side. So you compare the like if like and again, have a quick look and feel whether or not there is any sacred the mayor at the lower back and then in terms of listening, so we don't want to elicit breath sounds and we want to know whether or not they're, they're firstly, um, often in patient's who are long term admission's or have had domino surgery. It's actually, you won't hear much at the basis of the lungs because they're quite sort of clubs down. They have a degree of eight elected cysts actually won't be able to hear much. Um, you, you would want to comment on if you heard them and if they were clear or if they weren't clear whether there was an element of we've reputational crackles and you can also do local residents testing. So this is when you listen to, to the lung fields whilst you as a patient to say 99 if there's consolidation, that sort of conduct louder, so you would hear it louder one side with the consolidation. Um And then finally, um, you would want to have a very, um, quick, um, sorry, that's a wrong heading there, ignore the abdomen bit. So this is the conclusion. You would want to have a quick look at the observation chart again, um, as, as we said before, for the cardiovascular exam and in terms of investigations, you would want to get a sputum culture, possibly a peak flow. If it's relevant, for example, in asthma culinary function testing again can be quite useful in things like asthma COPD, uh potential chest X ray. Um That's quite important often, especially if you're thinking infection or a consolidation and also if they're desaturating, they also want to do an arterial stab. So an arterial blood gas is just something that is a blood sample you would typically take from the radio artery and uh there's a special machine that runs it so that one is more indicated in sort of you're acutely on. Well, patient's all patient's who are sort of very much desaturating and have high oxygen requirements because in A B G can tell you if they're a type one or type two respiratory failure and you can treat them accordingly. So as a respiratory exam, so just very quickly too summarize is the same sort of pattern as with the cardiovascular one, you start from the hands, you go work your way up to the face and then down towards the chest, the to the cardiovascular and respiratory example are quite similar in the way that they're set up. But there are some market differences. So definitely suggest that you to spend a little bit on of time just getting, getting to practice and getting your head around what those differences are and how they translate in terms of the pathology that you're looking for, okay, coming onto the abdomen. So, Domino exam, I'm not going to be saying anything you hear why PQQ set up general inspection and here you'd be looking for in terms of your clinical signs for pain. So, any obvious pain that the patient is in? So, are they sort of very much curl up on the bed not wanting to move or are they sort of very much writhing around trying to get comfortable? So, different types of abdominal pain could present in different ways. Um, any abdominal distension, um, the nutritional status of the patient's again, very quickly, have a look. Are they're very cachectic or they sort of very, very over way? Are they, is there anything obvious that you can see about then potentially about their nutritional status, just looking at them? And then obviously one of the ones that might, you might spot from the end of the bed is, is drawn this, so they're very, very drawn as you, you probably spot that they were looking quite yellow. And then in terms of bedside, you'd want to have a look at any medication, vomit balls off, then sometimes drains, especially if they've had abdominal surgery, they might have some, some dres still in situ and if they're on any IV fluids or even T P S O T P M s total parenteral nutrition. So that's for patient's who have struggled being fed through an energy. I should have probably listed energy as well. So they've got feeling two main nasogastric tube as as well. That that's something you can make a note of again, in exams, probably less likely. Um, they might sort of throw, like throwing a few bits, like, leave a vomit ball on the side or something like that. But definitely in real life, it's, it's a good idea just again to get a bit of a wholesome picture of this sort of patient that you might be dealing with. Starting and then again in the hands in the arms, you'd be again in, in terms of now abdominal size, looking for the patrons, um looking for clubbing, looking for Leukonychia, koilonychia. So, Leukonychia is whitening of the nails and then can suggest anemia and then uh sorry, hypoalbuminemia and koilonychia is like a spooning shape of the nail bed and that can suggest anemia. You also want to have a look at trauma. So often they get quite cause tremors as cirrhosis with with excessive alcohol use have a look at bruising. So bruising suggests that they've got impaired coagulations if someone bruises very easily is that then acquired neuropathy because it's secondary to liver disease. You don't have a quick look for any tracking. So sometimes with intravenous drug use, as you can see sort of uh bill phlebitis, tracking marks from, from injection sites and also tattoos. So tattoos, it's a bit before oh one, but you can get still sort of, there is a potential risk of hepatitis with tattoos, especially if someone have them done overseas or have them done somewhere where the needles may not have been sterilized as, as appropriately as they should have been. So definitely, just again, having an overall look at any, any of those signs. And then in terms of feeling, again, temperature pulse have a quick feel of the rate it will, but again, no need to worry about the brachial at this point, moving on to face, on his mouth and neck. So again, uh cushingoid features. So from sterile use or parotid enlargement, actually, both of those you can get in alcohol misuse as well or alcohol access or level liver disease, you can get angulus dermatitis as well. So cracking around the the edges of the lips, so that can, that can indicate iron deficiency anemia, glossitis can be a B 12 insufficiency. So they've got sort of a horrible swollen kind of tongue. Uh It's usually quite sort of shiny and all I want to say, I'm, I'm not seeing it in real life, but it's always one of the text expansion. Candidiasis is again, from long, long terms, they're uh steroid use. You can get candidacies in the mouth and up those ulcers. So these are sort of white, painful ulcers that form in the mouth, most typically associated with IBD, more of a crows. Then uh then you see. So those will be the things you look, look for in that sort of region and feeling again, offer up lymph nodes. So, and there were there was any red flags in symptoms, potentially have a look for lymph nodes. And if you're examining a patient in real life in an exam, do offer it up, but probably they'll just tell you to carry on, continue, continue with your examination. So at this point, we get onto the chest. So even though it's an abdominal exam, when we're going to have a quick look at the chest in the back, and in particular, we're looking for uh gynecomastia, which can arise from medication side effect as well as um high production of production. Sometimes you see, you see it also in um in alcoholic liver disease, you can get kind of panacea and you also look at speed spider Niva and these, we typically call it that sort of five or more is what we deem to be too many. So an abnormal finding, then we get to the abdomen, right. So we've done quite a bit. So it's very important to try and get through those initial bits quite quickly because it's quite a bit to get through in the ABDO exam. Now, so far up till this point, everything in this examination would have been done with a patient sort of a roughly 45 degree angle. When you get to the abdomen, you really want to make sure that you lie the patient flat, like completely flat because this will sort of help bring out any masses. Honey has anything at all. So by stretching out the abdomen, you will be able to elicit any size better. Really. So you want to um again, have a look distention of the abdomen, kaput medusa and scars. So again, we're having a quick revision here or the various different abdominal scars and what operation they may be indicative of. You want to have a feel. So you start with a general light palpations just to see whether or not there is any pain before you start palpating, always a good idea to ask patient if they're in any pain. And then you can start palpating deeper with the idea that indeed palpations, you would be able to feel any masses or veneers, but just make sure that the patient is comfortable white. Whilst you do that, you want to have a field, the liver margins and uh spleen margins as well as obviously, if there is very rampant hip Otto or a splenomegaly, then the texture, you might be able to make out the texture in a normal healthy person. You couldn't but have a look. Again, there's a lot of really good recordings on geeky medics, but you're sort of meant to take sort of the edge of the hand here as a patient to breathe in and breathe out and sort of help it be the liver with that uh and the spleen margins with sort of that angle of the hand. And then also obviously go around per cussing um the kidneys you want here sort of block from the bottom. So it's a bit of a funny way, but just pop your hands underneath the back. Warn the patient whether kidneys will sit and basically just tap up with your fingers and see whether or not you can feel the kidney again in a normal healthy person. Probably you wouldn't. But if someone's got polycystic kidney disease or having large kidneys and you might be able to sort of feel a mass rebound as you tap up your fingers. And that's what blotting the kidneys is uh percussion. So because for a societies and do shifting dollars, if, if, if you feel that the patient has a degree of societies and, and one thing I'm not listed here, but you can also try doing this feeling for uh a triple A. So technically, that would feel as though they heard a pulsar tile and expansile mass in, in sort of the middle or more towards the left, left side of the abdomen. I've not personally ever been able to feel one. The again is just worth doing and commenting that even if you were able to feel, be able to, you could probably say that it's pulse tub or not expensive. So, you know, immediately worried about a triple A essentially. But yeah, it's just one of those things that we do. If you were worried about a patient with the triple A, you definitely immediately want to and then to have some imaging in real life so, don't worry about it too much. And then in terms of glistening, uh, definitely have a listen to bowel sounds are very important in elderly patient who are prone to getting constipated, more prone to getting, uh, e s more prone to getting, uh, bowel obstructions and also your post surgical patient's as well. They've had abdominal surgery than obviously hearing the bowel sounds is the good, good sign that the bowels have started moving in again, in an exam setting. I don't think you were struggled to hear them. Mostly people are quite well. So you should be able to hear sort of the gurgling if you put your stethoscope on that to me, um that brings us onto the legs. So in terms of the legs would be looking for that peripherally dina again. Um And in addition, we'd be looking at systemic manifestation of uh of um gastro intestinal problems. So if you think by your erythema windows and quite uh kangaroos and again, often associated with IBD, so would would while you look at the legs have, have a quick look to see whether or not there is any dermatological manifestations at all. And in conclusion, again, observations review the obst our examinations, you could offer up doing a groin, an external genitalia example, depending when your findings, you might also want to do a digital rectal exam. So again, these are things that you would offer up, you will be required to do in in an in an exam setting. And then in terms of investigations, um so go to urine dip and imaging would be the things that you could offer. And again, these could help you. Then uh in terms of that differential diagnosis list, decide which one of those is more likely and less likely depending on what your findings would be. And that's your optical exam. So now we come on to the neuro exam side of things. So this is essentially the second half of the talk. And within the neuro side will go through cranial nerves will go through upper lower limb neurology and we'll do cerebella exam as well. So those would be your three main ones, additional ones that I would recommend looking and that I'm not going to go through today would be a Parkinson specific examination, examination of tremors and a, I'm sorry, my brain just went. So, yeah, Parkinson's and a treadmiller exam will be quite useful. But again, I'll try and give you some tools to approach neuro exams where these are definitely sort of the big bad difficult one, so to speak. Um But yeah, I do again, do have a look and and referred to other bits and bobs that you might be required to hide on as well. So without further a do the cranial nerves. So this table shows a summary of how to approach, examining cranial nerves one through six. And the next page will have the rest of them. Seven through to 12. I said this many times. I don't have great memory. So I always like pneumonic. Um And the way I remember cranial nerves, I got Toyota at medical school as, oh, once one takes the anatomy final, very good vacations are had. And that's literally just the first letter of each of those words stands for the same, you know, the first letter of the, now that they correspond to. So all factories spell right again, in an exam, I've never had to do a smell test on anyone. Technically, if you were doing it in real life, I'm told that you can get like a little selection of files and you've sort of folded up to the patient and they snip it and tell you when they can swell. I've never had all those sorts of files. I've basically gone in this patient. Have you noticed any changing smell since COVID? That's become a lot more relevant. But typically this one, if you just as a patient, have you noticed any change in your sense of smell? They'll probably in an exam, say no. And then you can move on to the optic nerve. So don't, don't get too bogged down. Realistically, you won't have to do very much for a olfactory nerve optic nerve. So there's a few bits to do here. So, acuity now, I if I've never seen acuity be having to be done as part of a cranial nerves examples. I've seen acuity having to be done as part of A I specific ophthalmology exam. So you gonna make I'm sure you have a look at one of those, but I've never seen it being having to be done as part of this exam. Like you offer it up. You say I will use a cell in tar at 6 m alternating letter and right, I obviously establishing whether or not the patient whereas um glasses or contact, but it's one of those things again that in an exam, you typically offer off when they tell you to move on visual fields. And as one way you as a patient to look directly at you cover one eye, sort of uh flick your fingers in the in sort of the at the extremes of their pills equation and do it with the other eye. And just while they're looking at you, make sure that they're able to see the peripheries to ensure that they will that peripheral vision intact. Um sometimes in an exam, you might have a patient who, who actually doesn't, who has some matter of hemianopia. And then, and this bit, I would really recommend going through that diagram which shows you sort of the disturbances of visual fields and what kind of pathology they correspond to. Because I've pretty sure I've had or heard of uh stations were essentially there was an abnormality with the visual fields. And then based on that you were asked, um, where you thought that abnormality was what it was and where the pathology was that went with it in, in October, you would also test for the pupillary reflex. Is that typically there will be a pen torch in the station for you to use. And then you will also offer up but not have to do a fungus exam. So again, that would be done with the ophthalmoscope. Typically, you would offer it and be told that it was fine. You can move past it, excuse me, three oculomotor, four chocolate and six of deuces Nate and group together. So you hear you do eye movement test, so you do your h and then up to the side and then the other side and you would do accommodation replace. So that's like holding up a pen to the patient's nose and being like look past me in the far corner and then flew down and pen and just making sure that you see that pupillary um change with in terms of looking far off into the distance and looking accommodating on on target, closer uh in the field of vision in 5 10 trigeminal. So you've got the three aspects here of the of the germinal norms know sometimes of the sensory testing. You would want to test light touch over the ophthalmic maxillary and mandibular area. So you would want to touch both sides of the face generally with their eyes closed and makes it make sure that it, they can feel it and feel it the same with both sides. In terms of motor. You want to make sure that they can open their drawers whilst you're trying to resist that movements against resistance. Then equally also ask them to clench their doors and, and have a feel along the side of the doors and make sure that it feels symmetrical as they're counting down. And then finally, excuse me, you would want to test corneal reflexes again. Typically you would offer it and you can do a drawer jerk reflex as well. Again, I would say typically offer it. I'm not, I don't think I've ever had to do it and make sound setting, but just make sure that you know what it is and how you would do it. Nerves seven through 12. So seven being patient, you will start off with testing the facial tones. So have a look for any uh well testing, I say for observing facial tones to have a look for any droop or a symmetry on either side of the face, the Imodium test again, all of these should be done against resistance. So raising of the eyebrows, scrunching applies, popping out cheeks and then giving a big 2 ft grin just to make sure that again, there is no asymmetry there and the motor innovation is, is the same on both sides. And then sensory wise, you could ask about change and taste because facial nerve innovates and terror, two thirds of the tongue. So you could, you could ask about the sensory side in eight best of it mm below cochlear. So you would wanna do a very, very rude of entry hearing test. And this was literally just whispering number in the patient's here whilst you're sort of like, like scuffing together your things on the other side. So basically have a noise destruction on the side that you're not testing to see whether or not they can hear you properly and ask them to repeat the number back to you. And then your special tests, your tune in full test would be your Rennie's and your favors. So you're really is, is the one where you use a Tune NG fork, you test bone conduction and you test air conduction. So you put, put the Tune NG fork under mastoid process to test bone conduction and then air conduction, you just hold it to the external auditory meatus. And normally, right, if there is no impairment, air bone air conduction should be bigger than better than bone conduction. And that's confusingly then called Renee's positive. So whenever we hear about a positive result, right, it's always bad, but Renee's positive is actually the normal, which is really confusing and then wait, this test is when you take your training walk, you put it in the middle. So in the forehead and then essentially in light of having done just release way that then allows you to differentiate between conductive and sensorineural hearing loss. So conductive will localize the bad air and sensorineural where localized the good air. Again, I can't recommend geeky medics enough. So have a look, they do like really good videos as well on it. It's all a bit confusing as I'm trying to explain it that if you're not quite sure, just look up so free knees invaders and look and definitely look up sort of the full run through of a cranial nerves. Example, the patient there, because it would just allow you to visualize it a bit better. And then in terms of nine glossopharyngeal, 10 Vegas and 12 hypoglossal. Again, we sort of love these together. Uh we test Bulba function. So we look at the symmetry of the, of the palate. So you ask the patient to open the mail and you have a look at the uvula and uh and the pallet and see whether or not the arches are symmetrical, listen to their speech. So just add them to talk and make sure it's not like slurred, it's clear speech with a good volume. So you can also do a swallow assessment. Again, you will offer up sort of uh or there might be a couple of water in the station and be like, please have a sip of water for me just to make sure that they're swallowing is normal. And then finally 11, which is the spinal accessory. So essentially this was most the Trapezius and the standard client investment. So Trapezius is structural, there's and push them down. So basically structural, there's literally against resistance. As then it kind of Estonia's turning of the head against resistance. So as a patient to turn the head and then push your hand away both sides like that. And that's pretty much it for cranial nerves. Excuse me. I've got a call. I've got such a tickly throat with it. They're in the one moment. So sorry. Um So coming onto the opera lowlands, so again, a bit of a memory tool. So the way I was told there and I remember it easily as I used mnemonic, I top cars. So the oh and the A are not relevant but the other, the consonants other than I are. So eyes for inspection. And then you just look at the consonants O T s for tone peers, for power sees for coordination, ours for reflexes and S s for sensation. Those would be the things that you would have to run through. Again. You don't have to do it in that order, but just having a structure helps remember. So whatever, whatever structure, whatever would or else be so long as you remember to go through all of it. So inspection um both umbrella. So let me we'll look for a symmetry, muscle wasting for circulation's any abnormal posturing. And then in, in the arms, you would want to have a look a Peroni to drift and then in the, in the feet, you'd want to have a look at soft tissue injury. Two of these, so things like neuropathic ulcers or even a shark, her foot from, from essentially lack of sensation and hence, injury to the to the joint would be relevant at this point in tone. So again, start from the one and then work your way the other end. So I tend to start from the wrist, shake their hand and then rotate the elbow and rotate the shoulder. So things that you might pick up here is in a Parkinson's patient, you would have that typically deemed called cogwheel rigidity where it's sort of like, it feels like there is almost like a cranking kind of motion as, as as you rotate the elbow and you rotate the wrist. And then similarly, in the, in the lower leg with the foot, you would want to do that circular motion and then flick the foot up. So that's to elicit the clonus. And with me, you would want to sort of give me a sudden little jerk pull from, from behind. And if the whole leg were to lift rather than just the knee that would indicate high tone. And then in terms of the hips, you just want to roll both legs, I decide and just see whether or not they're stiff and resisting that motion in power, just have a think about which nerve you innovates, which joints. So I think that's the best way of remembering it and have a little revision of that because sometimes again, they might ask you in terms of the full of questions that, oh, well, you notice do um impair, impair actual reduction. So what nerve roots that correspond to, for example, so it's worth having a look over these essentially again, in terms of your examination, start from the one and then work your way down. So chef powering shoulders, then elbows, wrist, finger thumbs and then equally sat with the hips, work your way down to knee, ankle victim. So it's just having that system in place for coordination. So with, with a pill, um you want to do sort of the finger, nose pointing and that's the test for any cerebella rate acciones. Similarly, you would also want to do hand slapping so that the, the decider co kind easier, which is the worst word ever. Um But both of those would be sort of cerebella signs. So we'll get onto the full list of cerebella signs when we're looking at that, that section. And for the lower, let me do, let me do sort of a heel shin shin test. Again, if you're not seeing one being done, just have a quick google of it, but essentially it's opposite heel to opposite me, run the heel down the entire length of the shin and kick up and do that on both sides. So again, um just have a quick look at that. If you're not familiar with Halston rue flexes would look out in the upper limb bicep stretch, tricep drugs and supinator jerk. So again, just get familiar with using a tendon hammer, uh, and then need your ankle drug for the lower limb and then you can do plant of reflex. So remember if you've got an upgoing plantar reflex in an adult, that's abnormal. That's basically good Minsky positive. So it's normal in babies because they sort of like withdrawing their feet. But in adults, it's kind of like the reflex would have been reversed because before the time spent Hawking, if that makes sense, so the planters should be down going if you strike the bottom of the feet, if they're up going in and that'll, that's probably suggest about off an upper but in your own, an Asian. And then sensation wise, you don't want to essentially attach uh sorry, test the different modality. So the light touching pain. So think about your derm, it'll thermal divisions and try and make sure that you would test across all of the divisions so that the epilemma would be C four C 5678 T one T two. So you don't want to, you'd want typically something like a cotton bud to test all of those dermatomes with. And then if you, you get given a neuro tips and like a small, not very sharp needle or still a small needle to prod each of those dermatomes without then assesses for pain. So like touching pain, assess all the damn terms, pro perception. So in um the hand, if we so for up and then we use the middle finger, this little inter phalangeal joint. So close your eyes, tell me if you're painting pink, if I'm pointing your finger up or down, up or down and sort of barrier between those two positions. And then in, in the foot, we use the big toes of the hallux to same idea, close patient closes their eyes and then they have to say whether they're sort of joint is being pointed down or up, um, official. This is a tuning fork test and typically, again, in a systematic way, just go through all of the bony prominences and both in both limbs. So you do shoulders, elbows, wrist finger, and then equally, we would do sort of over the, over the hips, over the pelvis and then you would do knee and ankle. So again, just assessing that vibration sense and hold the base of the turning fork to a burning permanence because that's where it can be felt best and temperature. Again, typically you would offer it up. But again, it's rare that you would ever actually have to do a full on temperature testing. It's more just as you're going through sort of attaching assessing light touch and pain. You can also sort of ask if you could basically put a hand either side on the patient and say, does the temperature my do has feel roughly the same. The reality is you're probably not going to do full, full on temperature testing in exam. And that basically concludes your exam. Uh, you would then essentially offer up MRI and the conduction studies as what, you know, in terms of what further investigations you would like to do from a neuro perspective. Uh CT is quick and I mean, if you thought that there was a very obvious like space occupying lesion or head injury or something like that, you could do something like CT head. But reality is that in, in Euro Land, MRI s tend to be a lot more valuable emphasize, but obviously, they do take longer as well and then you could do your E M G E G type neve conduction studies as well. So those would be or uh concluding remarks um that brings us onto the last exam of this talk, which is the Cerebella. So again, nice little know Monica Danish. Um it's quite well known get toy medical school. So things that definitely not miss in the Cerebella exam and is like cocaine Asia. So that's when you do the hand flipping from side to side a taxi a so make sure that you've seen the walk at some point um nystagmus in tension trauma. So I think you're thinking about things like your uh Parkinson's, for example, speech disturbance and hypotonia. So those would definitely be things to test for. Again, you set up the way as you normally would. You then do your inspection and you look for symmetry, muscle wasting fasciculation in, in the head. You look for us over the head, in the eyes. You look for uh nystagmus and you also get your patient to talk. You know, how's your day? How did you get here? What are you doing this afternoon? A few questions just to prompt them to give you a sample of their fluent speech. And you also have them to repeat something difficult like typically something like baby hippopotamus. Because if they've got speech disservice, the cardio speech slurring speech, they would probably struggle with that with, with those words, then you would do a quick opera low limb neuro assessment. So you would do essentially the tone, the power and the coordination that we've just discussed from the upper limb and lower limb neuro exam. So you wouldn't have to worry about doing the reflexes and doing the sensations, but you would definitely have to test the tone power and coordination. So, and you do that both for upper and for lower limb at this point. And then this is what I said about making sure that you've seen them also pushing gates of pusher, are they stable, sitting and standing and then make sure you do a Romberg's test them, them. Some Romberg's is when you said when you stand them up and then essentially get them to close their eyes, see how they sway. And that would be if they do a Strombergs positive. And then gate wise, what is they get like? Is it why based on steady irregular heel to tiptoe walking? So do look up like your various gate types and what pathology they would be associated with gait assistant is, is quite a big part of Parkinson's specific because that as well. And then in conclusion, again, at this point, it's not very much more else you could offer up an MRI head that you would like to do at this point to investigate for any, um, lesion's or any injury or any, uh, any, uh essentially any obvious pathology to, to the cerebellum itself. But I can really think of very much else to offer up in terms of investigations here rather than like an MRI of the head, including the, the entirety of the cerebellum as well. So in summary, uh I think we've said today many times just structure, structure structure. So just have a structure to hang everything off. It's not about knowing everything. It's basically that if you're a structured doctor, you're a safe doctor because yes, we all, we will all forget bits and Bobs at some point. It's not a big deal, but as low, as long as you have a structural approach with it, you're going to cover all of the most important things. And that's what will make you safe as a doctor. So, don't worry if you, you know, you come out of the exam and you're like, oh, I've got to ask about that. One particular thing doesn't matter. Okay. As long as you're safe and you cover all your bases, that's, that's what you want to be doing. Don't get too bogged outside an exam. If you get clinical signs given to you at this stage, chances are everything will be normal. Like your findings will be normal and don't be put off by that, ok? They wouldn't give you anything that's really like finnic A t if, if a patient had like a scar, it would be like it's bang in the middle of their chest somewhere on their chest somewhere. It would be like really, really obvious. So don't get too bogged down and go like, can I, can I not see something? Maybe is there? Maybe it's not just simply because remember it's quite time pressured, you have eight minutes in the station and your examination will be stopped around the six minute mark so that the examiner can ask you questions. So it's quite a lot to get through in that time. So just don't get bogged down if you're not sure, just keep moving, keep moving, keep moving. Um As you work through the examination, think about the purpose of each step and what you're trying to answer with that. So what is the potential pathology that you're checking for looking for. So, coming back to a difference is similarities and differences in terms of our cardiovascular respiratory exam. What it, it's really informed by is the pathology that you're looking for. Try and as you go along and it's quite hectic, it's quite busy or it's quite a mentally overloaded setting to be in particularly doing in an exam, but try and sort of come up with a list of differential that I know see that as you work your way through. Um And then like we said, any investigations that would kind of suggest the offer, think about how they would help you to differentiate between two diagnoses that for example, that you have in mind. And please please please do not forget your soft skills. So start with your work A Q Q, make sure that the patient is comfortable throughout. Um If you need to reposition them, if you need to expose them, let them know. So more often than not in my experience in these exams, they always ask the mock patient for a score as well in terms of if it were real life, would they feel comfortable with you examining them as a doctor? So just bear that in mind. So be very professional, very courteous and just make sure that the patient is comfortable, that's really, really important to the soft skills side of things. All right, I think that's all I've got for you guys today. Happy to take any questions. And like I said, please keep your eyes peeled because I will put on a second part of this talk with further examinations around muscular skeletal and thyroid bits. Definitely, I'll cover them separately cause it's quite a big, big area. So I didn't want to squeeze it all in today. But otherwise I'm happy to take any questions and equally happy for us. Email me as well with any questions. You. Yes. Hi doctor. I've got a couple of questions actually. Yeah. First of all, um this is very good. Thank you very much. Is it possible for you to actually have this um this slide? Because this is very like informative and it's just really good. It sums up everything because I struggle a lot with this. Yeah, that's not a problem. I will, I will make them available. So if you're are you in the CRF groups on whatsapp? Perfect. Which, which one are you on? The first group was on day? Uh Well, I'm I am not one of them I think because there are two groups. Yeah. OK. Don't worry. I will, I will literally create a PDF printout later on today and I will ask uh Hannah slash Karen. I'm in group A he says group, a urine group. A okay. Yeah, that's fine. I'll make sure that they get sent out to my Yeah, CRF student group A Yes. Yeah. Okay. That's fine. I'll make sure it gets posted then. That's not a problem. Thank you. And my next, my next question is um this um examinations that you just went through with. Um Do you only do it when um just for, when you're applying for registration only at the F one level? Like for example, or do you continue to do it? I should move on in your training. The answer is it never goes away, you keep doing it further. Um So basically it in, in various shapes or forms. So they will always, these exams were, these examinations will always structure the same way in exams, they will just progressively get harder. So you do them when you graduate medical school, so you do them as part of your finals. Okay. So in finals and in, in sort of a level of an F one F two doctor, they wouldn't give you anything too difficult, like I mentioned, they wouldn't give you any really tricky size. Okay, then if you did something like a membership exam, so either the M R C E P which is the member of the Royal College of Physicians or if you did F R C A which is a fellow of the Royal College of Anesthetists or mrcs, which is a member of the Royal College Officers and so on. So when you did your membership exams, you would still have to do the same examination, but there you might get something a bit trickier like they would then have to start picking up signs. You would have to think about every time you do them, they get a bit harder. If that makes sense of what you need to pick up becomes a bit harder. Okay. So basically every time you're moving up in your training career or from starting from F white one to be, you'll be doing this uh stations examinations. Basically, essentially every time you have uh an exam that is related to your career progression as in your stage of training. Yes, you will have to do practical exams on some level and that will involve these examination skills. Yes. OK. Lovely. And finally, um at this stage, um when we finish medical school, for example, maybe if you're doing a to get registration or in your finals when you go for this um exams, um do you get uh pay studies in order for you to know that you need to do cardio examination or opt to me or ophthalmology examination or do you or does it say in each station, does he say okay, perform um neuro examination? It will be very, yeah, it will be very, very explicit. So in your exam, so be at the platte to or whatever other exam that you say, which is of this or ski former, the blurb. So you get a little description of the station will be very, very explicit. It will say, you know, Mr Smith is 60 eight is come in feeling short of breath, please perform a cardiovascular examination and discuss your findings with the examiner. It will be along those lines. Okay. So basically you get the short or brief of the case, case studies and then you'll get a big word that would, that would say please perform uh neuro examination or cardio examination. So that way, at least you're able to know that. Okay. This is the kind of examination I need to do cardio because if, if I'm supposed to do cardio, I don't want to be doing neural. You know what I mean? You will know. All right. Exactly. Yeah. Yeah. Yeah, absolutely. There is sometimes much to the annoyance of some test takers is a bit of ambiguity, Sino. In one year in my university, they asked for a chest exam and a lot of test takers felt that that was unfair because was that then a cardiovascular or was that then a respiratory? Exactly. Exactly. But actually what they then did, they said okay, fine. That was ambiguous. So they would have accepted either one at that point.