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Right. But Sammy, so I hear you. Don't hear me. Yeah. Ok. Oh, f can hear you. No. Yeah. Mhm. Mhm. Sorry guys, if any of you are here, um we'll be joining, we'll be starting in about like 55, 10 minutes. Uh Yeah, our speaker is currently um having some technical difficulties but we'll get going in in five minutes. Thank you for those who are here here. Um You can join back in five minutes if you want to but yeah, just introduce myself a bit. Um My name is Isha. I'm a second Emetic uh Imperial. Um So yeah, this talk is also like helpful for me as well. Uh But Bursa speaker, he's a um uh fifth year um at Imperial College, London. You can see him over here. Um Just completed a prize winning I BSC in business management and he's fresh on the sticks again doing um But, so what placement are you at right now? My replacement. Uh Yeah. Yeah. Oh, lovely stuff. Ok. Yeah, pediatrics. So yeah, he's got tons of explorers throughout 2nd, 3rd, 4th year. Um He'll be sharing a lot mainly on examinations um today which is take of the b of 2nd and 3rd year to be fair. Um, it's something that I need to learn as well, so I'll be playing a close eye. Um, but yeah, we'll start on like 5, 10 minutes books. Um, and then we'll see how it goes. Yeah, cool. All right. Uh, if you wanna share your screen as well. Yeah, just, I'm just gonna, I just give me a second. Sure. Ok. Can you still see me? Yeah cool. Wait, wait can I see you? No, I can see you actually. No close. All right. Give me a second. Ok. OK. I'm I might I might I'm trying to get the sides up. Just give me a sec. Why is it working? Yeah, he'll be starting in about five minutes so yeah sorry. So I'm trying to basically share my screen but it doesn't let me do it. Just give me a second try out. If not then I send it over to me, I'll try it so I share it. Cool. Yeah, I'll share for mine. That's up. Great. Um I'm sharing slides now. Yeah. Yeah cool. Uh OK. Yeah and then put it on slide show mode that should be fine. I'll get it up on here as well so I don't know and then I'll tell you when to like change slides. Sorry, I don't know. Sure. Cool. Um All right cool because wait should we hold on one second? Hold on one second. Got it. Uh we'll start now, probably, probably the best time to start. Um All right guys. Uh sorry for the screen you probably see right now. It's not the greatest. Um But we have some technical difficulties you have to do with what we have. Um The, the, the connection is not great either. But yeah, so my name is Isha. I'm a second year medical student at Imperial. Um uh Today is not about me though. Today is uh about Rohan. Uh He's our fifth year uh Imperial as well. He's just finished his uh prize winning I BSC in management. Um And today we'll be going through uh a lot of skills that you might have forgotten, er, in 2nd and 3rd year. Um that, that, that are pretty important, mainly er, clinical examinations but it also includes some bits on interpreting EC GS, er spirometries and stuff. Um but it is key to passing a lot of people, for example, clinical exams and then going up os et cetera um for any questions, just type them in the chart. Brian will uh will he have an open and he will um sort of uh answer them a along the way. Um Anything else then? Just, yeah, feel free to contact me. Uh My name is Isha Sharma. Uh and then you have his uh sort of um email on the screen as well. Um So without any further ado I'll just pass over. Yeah. Um, do you think uh you've got the sign up? Ok, cool. Ok. Hi guys, I'm Rohan. I'm the fifth Student Imperial. Er, as I share just mentioned, I've just completed my management at I VSC. Um and now I'm doing back to doing medicine. So kind of this is kind of useful in a way for me as well because you know, um kind of re kind of getting my clinical skills back uh kind of takes time So it does, um, and it is important and I will say that at a young, a stage of 2nd, 3rd year you wanna build up your basic skills because in osk, all they want is just be very clear and to kind of think, you know, what you're doing have confidence and that's honestly the main thing as you, as you kind of see. Um, so if you just share, if we go to, if we, yep. Ok. So in this um talk, uh I'm mainly focusing on the basic examinations. Um I know originally we did say we will do a little bit of we on the other stuff and kind of er, imaging. But I figured that kind of in this kind of like 45 minute, maybe less er, session, the main thing to focus on will be examinations at this kind of level because that is like the bulk of your ay marks, your CPA or whatever kind of, er, test you do in your universities. That'll be the bulk of your marks and I have put a little bit of lung function test and E CG some kind of basics. And then you can kind of go in, you know, have, if you have any other questions about EC GS lung function tests or whatever we can, that can be done at a later date. But I'll do like a general overview of that uh next time. Um OK, so first what I wanted to start to do is just talk a little bit about kind of uh pointers. Um Make sure you can hear me right. I just wanted to check and check. All right, cool. Yeah. Ok. So the main thing about um at year level, year two year three is that patients in general, I know Imperial and I'm not sure about every university, but I know imperial patients do not have any signs in their exams. So what you're mainly doing and what they're mainly testing for an exam technique and that will generally be um just doing the exam clearly, effectively having a clear mannerism, being professional and having a clear, confident, patient manner. And also, again, the biggest thing honestly is the feeling like, you know what you're doing, even if you've forgotten something or forgotten how to do it. If you've shown like what you're doing or shown the system that you're doing, you'll generally get enough marks for it. And that's hon that's honestly one of the biggest things. Um ok. So what I wanted to start with is kind of introduction because um so I know in second year for Imperial, they call it CPA. And then obviously for Ays as well, you get a bunch of marks about 25% almost, not quite, but 20% at the beginning for literally just doing all the intro stuff. And if you do all these things you can cover like, you know, a third of the marks you need to pass the station. Now, the first thing you need to do is always wash your hands. When you enter a station, you need to, you, they'll have their hand or whatever, hand sanitizer and just make sure you wash your hands. Some people put gloves on you, it's completely up to you. You don't, don't have to, but that is like ama massive thing. Now, the second thing is that you want to introduce yourself, you wanna say, actually, I'll say I I'm over here whatever. Um and just make that clear for the first day. Now, really important thing you need to do and you need to get used to this for your actual clinical placements is to check the name and date of birth of the patient if you cos because, and, and the reason for that is because it can be very kind of dangerous to not know the name and date of the patient obviously. So that is a clear thing. So just check the name and date of birth and then proceed and then what you need to do is explain the examination to a patient. So you can say today I'm performing. So I've put this an example of cardio but you have multiple examinations. So, so today I'm performing a cardiovascular examination. Um and what you want to do is not make them too intimidated. So just make it and also make it kind of patient language simple for the patient. So let say this is when we looking from the end of the bed, you know, fe uh feeling a pulse in your wrist and just having a quick listen to your chest and having a feeling a pulse in your neck. Um and it doesn't have to be more complicated, don't make it too complicated for them. That's generally it uh the important thing is to check for pain. So if you have uh pain in a certain area, you don't want to kind of um examination in our area because it will be difficult to kind of it, it it will be difficult for them unless obviously you absolutely have to. Um But generally it shouldn't be a problem at your level, at that kind of year two year three level, you just need to ask that they have any pain, make sure they have no, any questions before procedure. Um So one other thing is also uh you need to ask help with undressing. So um I if they for example, they might need a certain exposure. For example, in cardio, you might need to have them or, or respirator, you need to take their come take the tshirt off or shirt off. So you need, you wanna make sure that they need any help with that and they have the correct exposure. And the other thing is also is the angle of the bed. Uh That's the important thing as well and you also want to um gain consent from a patient. Uh So you need to actually make sure that they actually consent you to do an examination. Uh next slide. OK. So for the cardio examination, when I said uh about the exposure you want er sorry for the angle, the bed, you wanna do it to a 45 degree angle um just to examine them properly. And then once you do this, you want to do a general inspection. So another thing is you might wanna, yeah, you want to expose the chest, so ask them to take their tshirt off. Um So what you wanna do is uh OK. The reason I put demographics in there actually is um er I know it seems a little bit weird but what it actually means is that as part of general and inspection you want to actually look at. Um So I know I do remember in year three when they taught, taught us is that you wanna check like their, their age, their gender ethnicity weight because that actually, I, uh, kind of helps with a lot of diagnosis, which is quite interesting. Now, with, um, cardio, what you wanna look at is there are certain signs you wanna look at which will become more clear later. Is that what you just? Ok, the key thing I, the, the, the key thing I'd say about signs is that the first you need to make sure, you know what you're doing in the exam. If you're going, if you can know the exact steps of a cardio exam, then you don't need to exactly worry about what the signs will look like cos at this level. And I still don't know what them look like. You just need to know if they ask you in an ocular or CPA what you know, a sign would be, then you just need to make, make sure you know what it actually is not exactly how to identify it. So the key thing is just going through all these steps. So even when I put in there, look for signs of silence or shortness of breath power, all you need really need to do is just look at a patient and see, ok. Do they have any discoloration? Do they look or do they look unwell? The biggest thing is the generally the most important thing is to look unwell because that would be like the key, most important indicators. Do they look like they're struggling with breath? Or do they look like they have pain or do they look like? Yeah, there a discoloration, uh, or they have a, or they have a flush or a rash? Um, so that's the biggest thing. Look for, also signs around the bed and that would be different for different examinations. So, for rest, it might be that they, do they have any inhalers or do they have any, uh, oxygen? But, um, but so for cardio it would be things like, do they have any GTN spray? Do they, what observations do they need? Do they have um, a cardiac monitor on them or do they have a pacemaker? Anything like that? Uh, next slide of you? Does that work? Ok. So now what you wanna do next is that, yeah, is that right? Ok. So what we wanna do next is that you need to inspect your hands. So the first kind of thing you want to look at is uh the signs of clubbing. So what you need to do clubbing is you need to get the two index fingers and just put it together like this. I need to look. So there's a window and with that window you wanna find if um that window is it actually gone? Um, if that window is gone, then it's usually a sign of quite a few things and they aren't just all for cardia. They, in fact, you want to do them for all the examinations because they usually indicate a few kind of, um, pathologies. Now, also, when you look at that, I've put things called, uh, oss, er, January lesions, splinter hemorrhages. They're essentially like, you don't need to worry too much about them. But it's the reason in there is because if they ask you, you know, what are you looking for in the hands, it would just lead to these things. Signs of infective endocarditis, which should, it's like it's a heart condition and you want to essentially, that would be a sign of that. Uh If they also ask you for causes of clubbing, that would be, there's three, there's three main causes that they'd ask you one. So one would be infective endocarditis. So it would be the infection, another would be er congenital heart disease uh in a, in a newborn. And the last one would be atrial myxoma, which is a very rare kind of heart tumor. But again, you don't need to worry too much about it. Just know those are the causes. Now you wanna check the hands. Uh You wanna like said, you just check the temperature back and forth like this and those are cool hands might suggest poor perfusion, but sweaty hands might be associated with er coronary syndrome because kind of um stress on the body. Um Now what you wanna do is er measure the cap refill time. Now this is important because you wanna check um kind of like again, the perfusion into the nail bed. So you wanna apply five seconds of pressure to the nail bed, obviously the index finger and then you wanna release. Um Now, if it, it should return in less than two seconds and if it return and if it takes more than two seconds to return, then this suggests poor for fusion, which again might be uh no, no hypovolemia, so low volume or heart failure. Um Now, what you need to do this next is uh feel for the radial pulse. I'm sure we, we've all felt for the pulse. Um uh So I shouldn't have to go too much into that, but kind of what you need to make sure you do is with the radial pulse. So that's essentially you have the two pulses, the ulnar on the kind of the uh medial side and the radial on the outside. And you want to take three of the fingers and measure the radial pulse on the outside. Um And what um I'd usually do with the um this is just do it for 15 seconds and then times it by four. But uh just tell the patient you're going to measure the pulse. Um Another thing, the next thing you actually need to do is something called collapsing pulse. So, what you actually need to do is that you need to essentially raise a patient's uh arm. And well, first of all, you need to do is that you need to palpate your pulse and then once you take the arm, you need to raise it above their head briskly. And now you need to keep your fingers on there and if you feel blood, you won't feel it. But what you, what you're essentially feeling for is if blood getting empties or for, um, no, well, not empty, it's meant to, but if there's like a tapping impulse, it's, it's just called ac need to remember the name of again, you won't feel it. Um And then another thing they'll ask you to do is just offer. So in an actual CP osk, they might say you, you need to say you need to offer certain things but not actually do them. So you'd say I'm offering BP to measure BP and you say sitting and standing because uh sta sitting and to change, sitting and standing can be a sign of um uh postural hypertension or when your BP changes and standing or sitting and also radio radial delay. So that can be signs of kind of picture of heart disease. Again, you'll never see this. But you, you just need to know these terms to say really. That's it, that side. OK. So now what um OK. So I'm again, I'm not sure exactly what level you are. But if you have been taught about the cardiovascular examination, what sometimes they will tell you is that you need to listen to a carotid pulse first before um, before actually feeling it. And have you been taught this? I like to know. Yeah. You'll, you'll miss it. You miss it. Good. Sorry. No. No, just, ok. Don't worry. Uh, I'll give the mic on, uh, and help you out a bit. Um, no, no, no, we haven't really been taught this to me. Oh, we may have, but I might have forgotten. But, um, no, that's fine. There's nothing wrong. It would be worth it. Yeah. Ok. So I know for a fact that, um, what they do t teach you in this is just more of a thing for you, for you guys. I'm teaching you to know because it's not only just for exams, but one thing they do tell you is that if you, um, in real life, if you, um, feel someone's pulse and you haven't listened to see if they have a bruit and you touch their pulse, you can actually give them a stroke. Now, I've actually done this and I've not, and I, this is, I've luckily touched that it never happened to me. But the reason I tell you this for exams is because apparent supposedly in real life you could give someone a stroke like this. Now, I have no idea if this is stroke but just follow what they say. That was just a random piece of fact. So, what you need to do is first a tape. So you need to first listen over the carotid arteries in the neck, uh, both sides and, uh, you need to do it with the bowel, I believe. Er, and you need to, then, um, basically if no bruise again, your patients will be normal, you need to then palpate it, er, just like you just feel the pulse in your neck and do not feel both at the same time because you, you make some, um, yeah, and then essentially what you need to do next is something called the JVP. So you have the, um, the J BP is just uh kind of another way of measuring, you know, a venous pressure. But I in patients with heart failure, it will be a raise and you can actually kind of like see it, it will, it will be longer than usual. Again, you won't see any, but all you need to do is you need to tell a patient to turn their head slightly to the left and then you'll be able to, you won't see it. Um It, the, the ways there is a way to make it, be able to see it. Um And that's something called the hepatojugular reflux. Uh You really don't wanna do that on a patient cos to be honest, pretty painful. And you just again, that's something you just, you just offer it because you just don't wanna do that. Um And yeah, and that's the cause of that would just be usually rightly kind of heart failure or uh tr or regurgitation, just know that as a cause again. Uh so next, what you wanna do is look at the eyes. Uh you will look at all the three examinations I'll go through, you will need, you will look at the eyes um um because they can use for a lot. Um And honestly, one of the main things you do, I know you may have done this before just in general is look at like to look, to see if your eye is literally pale and that will just identify signs of anemia. So it's pretty simple like that. Er, another thing will be uh something called Xanthan asthma, which would be kind of cholesterol deposits. Uh That's like hypocholesterolemia. Er, again, you won't see any of since just a moment. Um Now, what we want to also do because uh look at the mouth. Uh So you want to ask them to raise the song to the roof of their mouth like so, and then you, that will then basically essentially look for like problems with dental hygiene, but also um something called high arch palate, which you'll find in Marfan syndrome. Um just some things that are there. Um So next you wanna move on to the chest um and first you wanna look for inspector chest and I'll be looking at things for scars. So there's very scars that you can have obviously off the top of my head. I can't remember a lot of them, but there is something called a Mid Larsen toy which will be done for a cardiac surgery. Um, but what you need to do ask them is actually look to raise their, the, to look under the axilla. So, just look under both sides and you won't see both of the scars. You also can find chest wall deformities. Um, and one of the main ones would be, uh, well, they're basically, it's called pectus excavatum where it's ac in chest, er or it's also carum, which is a protrusion in the ribs. Uh again, re just remember for most of this, you won't see any, this, all you just need to know is if they ask you, this is what you're looking for. Uh Now, what you need to do is uh is something called a measure to feel for something called a heave, it's called a parasternal heave. You basically need to put the heel of your hand parallel to the sternal, left sternal wedge. And so that's just literally here. Um and just put it literally at the bottom of your hand, you don't just don't put your whole hand on the chest. And if kind of there is like your heart is slightly bigger or ventricular hypertrophy, it will actually lift technically. Um then there's something called thrills and that's just basically turbulent blood flow, er which again is a by pathological sign which you won't see. But what you need to do is put your hand across all four valves and I'll go through the, er, where to put the locations of where to put everything in the, in on the next slide. So you'll see. Er, yeah. Um, so, so if you can change the light and then it'll actually become, uh, I do the diagram, I know there's a table there but that diagrams the next slice and then it'll be able to clear what that table means. So if you look kind of here, you'll see the mitral valves just in the orange, the tricuspis in the red and then they're able to compel man. So if you go back and show, so that's my bad. They're not on the stage. So we go back one side. Yeah. So now you can see this table here. So essentially to, to ex extenuate the sounds in those areas you want to measure in the times in this table. So the mitral val will be the fifth intercostal space. The way I do for obviously, if you go on the wards, you won't see consultants to us or registrars. But at kind of when I was at a level, the main thing is literally start at the kind of like bony part here and literally just count your way down the ribs, that is honestly the best way to do it. Um because you'll find that the, the second or to space there and you'll literally just count your way down. Um So you can go on the next time. That's fine. Um, next, uh, basically what we need to do is, uh, auscultate heart. Now, you, I'm sure you've seen everyone do this but there is like, obviously like a specific, um, way to do it. And, uh, as I put those literal areas I put before you as the way you, where you feel thrills, you also listen in those areas of the heart. So, but they're not exactly where the heart valves are, they're just where you listen, the heart valves are actually in a different position. Er, but they just listen in a different area. Um, now there are certain other move maneuvers you have to do. So it's not just, you don't just listen to the area. So to these four conditions, like are all valve, valve, valvular heart conditions. Um, and you need to do certain maneuvers to try and figure out the murmur for all of them. Again, you'll never hear any a, uh, to be honest, I think, I bet, I think I've probably maybe heard the first one and that's it. Like I, you won't actually hear any of this, but again, it's just if they ask you. So the first one is aortic stenosis, that's the most common I believe. Er, and the murmurs ejection, systo systolic. Um, I mean, you just, you just have to know that's more in the contraction phase where there's dias, so just in the resting phase. Now, to figure out what your, to find out what you need to do is listen to the carotids, um, while they're taking a deep breath in and now it's, that, that's pretty much it. And it would, it, the mum will be and supposedly it, we would always hear that. Now, a reg good you're meant to, you're meant to get them to sit forward and then you meant to, and then get them to take deep breaths in and out and then listen to the lower left sternal border. Um So again, that would just be around the bottom here that I believe it to me. Yeah. And then sorry, and then you need to then also take deep breaths in and out. Um And you should be able to hit a murmur there. Er, so for mitral regurg and stenosis, actually, you need to tell them to roll to the left. Um And what you need to do is uh listen, while rolling, roll, getting them to roll to the left, you need to listen, using the diaphragm and then the, and then the bell for mitral stenosis to see if it radiates into the axilla or into the armpit. So those are the ways essentially of finding out the murmurs. You won't hear any of them. You just need to do them in the exam. He'll go next this year. Uh OK. So next is rest of examination was ever ok with the cardio, if any questions you can write on the chart you can try. Ok. No. Ok. Um So for respiratory, now, respiratory is actually very similar. Um there aren't too many differences. So it's um it generally kind of go hand in hand. So if you know one, you should be able to get a lot of the others. Um Now, for general inspection, what you wanna look at is signs of, you know, basic things again or do they feel them? Well? Are they coughing a lot? Are they wheezing? Uh do, do they look pale anything like that? Uh a lot again, treatments around the bed is a bigger thing. So, you know, look for oxygen, see if they have any sputum po see if they have any inhalers, anything like that. Um So what you wanna do is first again, expect the hands. So again, you need to feel for both sides or hands like this with the back of your hands for temperature. Uh And then you also need to do the clubbing. So literally kind of two fingers like this. And I would literally be looking uh in this case of a recipe would be things like lung cancer kind of um lung disease like cystic fibrosis. Um Again, that'll if you just remember those three if they ask you. Um But yeah, uh another thing you need to do is kind of tell someone to hold their hand out and if they have like a tremor, it would they might, it, it would be able to see if their, their hands are kind of shaking around and that would be usually caused by salbutamol use. Um, now another thing is something called a asterixis. So this would essentially be, er, if you tell someone to kind of tell them to cock their wrist, they put their hands up, cock their wrist back and I believe, close their eyes but don't think you have to and then tell them to do that for 30 seconds. And if you see like a little flap, um this is something you might actually see, I even saw it in like my first year of my placement. So you might actually see this. Um and one of the causes, main causes would be like, you know, CO PD or anything that causes CO2 retention um will cause that uh from a point of view. Um Next thing to do is um your pulse, er just like the cardio exam. But uh what you also wanna do is respirate. Um So, and this can be very, a little bit challenging to do at the same time, which though it does take a bit of practice, it does take me a little, a little bit of a long time to do. Um But the important thing is do not tell a patient that you're measuring their respiratory rate because it will tell them it will be, they'll be conscious of their breathing. So you just tell them, OK, I wanna measure your pulse now and while you're measuring their pulse, look at their, their chest to see if it's moving up and down, essentially, uh that's fine. And then, uh next is J BP, which I explained is the exact same as previously. Just tell the person uh patient to turn their face to the left and then look to see um if there's any kind of pulsation, uh you probably won't see any. Um, and then again, you wanna look at their face again this time and you wanna see if they have any. Um, again, if they look pale or again, tell them to um, open their mouth, um and raise their tongue to roof their mouth again. So, uh pretty much exactly the same. Uh Yeah. Ok. Um So next is uh palpating the tria. Um This can be a little bit uncomfortable but essentially you just wanna like find like the, like just literally right here and you just wanna place your two fingers there just to, just to the tria and you wanna go a little bit mid, a little bit lateral, er, on either side to see if the trachea moved, er, and it would be kind of over your Adams Apple here as well. Um Now if you feel like the trachea has moved or if you can feel the tissues on one side, it's usually caused by neurotrac, um, we'll give you a feel it. Uh, so then we also did something called crico theal distance. Um This would, this is the distance to the, you know, the cricoid cartilage uh here and the supra, so the cricoid cartilage here and the suprasternal notch, uh and you wanna put like the three fingers here. Um And it should be that you should, if you can kind of the, the distance should be 3 to 4 fingers. Uh If it's different, then it's usually if your lungs are hyperinflated or if there's more because like the air would be kind of pulling through it. Um Now you want your, the first thing you wanna do is chest expansion. Um What you need to do is put your hands on the 10th rib of a person. Um That can be a little bit difficult to kind of visualize, but it will literally just be like right here at the bottom of their ribs almost but not quite. Um Now, what you need to tell them to do is literally ask a patient to breathe in deeply and watch their to move a move apart. You need to put the ha you need to wrap their hands around their chest. The mistake I was making on the wards in secondary and third year was I put the hands just on the front. So your hands would actually move. And when a consultant comes and asks me and say, have you done the examination or if they're watching me, I would literally just move my fingers and be because like I didn't know what I was doing, but to actually fix that, all you need to do is wrap their hands around the chest and then your fingers will actually move to the side. Um So yeah, but don't do that. But so the, the important thing is wrap your fingers around and let, and you, you, if you put it in the right place, your hands will move above. Uh it should be equal on both sides. Yeah. Uh If it's not equal on both sides, um then that's usually a problem with kind of um inflation on one side usually or a new potentially, there are multiple causes. Um Now, next thing you wanna do is uh palpate the apex beat. Um Now I think I've actually completely forgot to put it in the cardio vascular examination for some reason, which is very strange, but you need to do this on both on the cardiovascular and the respiratory examination. And you need to find the mid um fit across space, mid curricular line and then you need to literally just put your hand there. Um And you should be able to feel their, their uh heartbeat. Um uh Usually if you don't, it's not that there's something wrong. It's usually because like their hearts not beating very fast. So in real life, you probably feel something wrong or something. But in this case, you just feel try and feel that you should be able to. Um, now, next, what you need to do is, um uh because so essentially what you need to do here is you need to get your kind of two index fingers just like this. I'm not swearing in case you're wondering, and then take your index finger on the right and literally just tap it just at the front almost near the nail. And that, and then practices that on a hard surface and you need to then tap that on the patient's chest. Um It, it uh I'll show you on the next slide once and she changes it. Er, and that will essentially uh not yet. No. Uh and that will essentially kind of in those areas, you'll be able to identify if you hear the sounds of difference. So there's dullness, resonance, um resonance will be a little bit higher. Patient dullness will be a bit lower. And if you hear those different sounds, then forget your word. But the whole point is to hear those sounds when they ask you is that you're looking to see if there's um kind of diseases. So resonance is normal, but if it feels dull, then it's usually um if it feels dull and there's usually kind of um yeah, uh it's usually cardiac abdomin. So uh all, all that's over the cardiac area. But otherwise it's usually because there's kind of consolidation or a tumor or kind of solid mass there. But our hyperresonance is the opposite. There's usually air because the pneumo is air. So that's what why those sounds are heard. Uh If you go, you should. Um so next you want to do is tactile from um for those of you go to er, you may have seen a video of professor me do this but um essentially all it is is um for all, essentially all this is is that um you, there's two ways you can do this, you can either do it with a stethoscope, you can do with your hands. I prefer my hands. You already put your hands like so and you tell patients to say 99 and then you put their hands and then you put their hands on their chest and then say 99 99 99 like 33 kind of three times down the chest. Um Now, increased vibration uh will be kind of, it's similar to before. So it's increased tissue density. So it's usually caused by like a tumor or consolidation, decreased vibration is usually like air. So that's why it be or fluid. So that's why it's a pleural infusion which is fluid or pneumothorax, which is air. Er Next you wanna er listen. So if you look at that um that picture that will also be where you want to do the percussion to um as well. Not the though that's slightly different. Actually, you can, you can do the same um for um now for auscultation, if you have a look at the, I appreciate it might be the biggest picture. But if you have a look at the picture on the left and you go all the way from, yeah, that one, if you go all the way from 11223, you can see it's an s shaped, that's actually the best way to do it. If you follow that little s shape, it's usually the best way to do it. Um Posterior is a little bit different. Uh You just do it wherever you, wherever you, as long as you're doing in those areas. Um So for auscultation, you're essentially just listening for uh breathing sounds um that to listen to normal and abnormal breathing sounds. Um And what you want to say is that again and tell them to take deep breaths in and out but, and then hold, um you wanna ask them, you want basically listening for. So uh for added sounds. Um Now these added sounds and you might actually hear these. So if you hear um a wheeze that was usually an expiratory um kind of there will be some of you hear while breathing out and that will be usually caused by obstructive lung diseases which are called COPD asthma. Um Right. And then there'll be something. Now, the next one is something called Stridor. Now, I've actually personally never heard this. This is usually something in inspiration and you might hear it in, er, somebody who has like a, a airway obstruction or you might hear it in like younger, young, young Children, for example. Um, with, but you just essentially, I, these are just to know if they ask. Uh, another thing is, er, crackles, er, coarse crackles, which will literally be like really rough crackles will be kind of a pneumonia or lung infection and then finding the spiritual crackles a way to know this. Um, I only got taught this literally like two days ago is that if you take your hair and rub it, that is actually what in the spiritual crackle was meant to sound like. Uh, yeah, but I only know this two days ago. Interesting. Uh, and now are usually things called uh pulmonary fibrosis with a restrictive lung disease. Um, you sure you can go next. Er, so this, er, picture essentially, I've actually nicked this from er, one of our, er, lectures from third year, essentially just showing the different areas and you can look at this kind of your own time, but it's just essentially showing that from these different conditions, you get um, different added sounds in different areas and then different and then also different breath sounds. So it'll be decreased in certain conditions and increased numbers. Uh, you can go next, that's fine. Uh So we're almost set at the end of that examination. But essentially, um, now you wanna feel for the lymph nodes, you wanna go from, you wanna go behind a patient and then tell them sit up and then kind of er, feel with your two fingers and just really like properly, deeply filled for the lymph nodes in different areas. Um Yeah, and then they will be different as a, there'll be the maxillary, er, lympho mastoid at the back. You are occipital right here and then submental, er, superficial cervical and then deep cervical. Um So you just need to do, you need to go from behind a patient and really like uh massage, essentially massage for the er important thing. Repeat for the posterior chest because the sounds you try and hear with respiratory can be a little bit difficult on the anterior because of um because your heart's but um if you repeat it in that area, it'll be uh you'll be able to hear more. So when I go on the ward, I only hear it in the back. I don't really use the front unless you wanna check for sacral um pedal edema. So I believe you do this again. This might, I've actually forgotten to write some cardia as well. You need to check it to see if there's any edema that's caused by pulmonary causes or cardiac causes. And that will essentially come up as like um kind of like in the back. So you wanna feel for the back and also the legs to see if there's any edema. Uh I believe that's the end of respiratory. Does anyone they ever understand what I mean? But can you explain the, um, and the, uh, expiratory sort of crackles again? Oh yeah. So, er, again, this is actually, so that essentially what that is, is, again, it only essential properly a few days ago I could pre, it's a little bit difficult to understand is that when you, so when you listen to, for these sounds, certain ones will be, you'll hear more when you breathe out. So that's like wheeze. So when you have some time to breathe in, it'll be very normal in somebody who has asthma or COPD. Um and when you tell them to breathe out, it literally, ah but when they breathe in, you can't really hear much. So the inspiration is the opposite. When they breathe out, it'll be fine. But when they breathe in, it will literally sound like very fine like noise like literally like flicking like this. Um And what that basically just means is that there's a restrict restrictive problem. So pulmonary fibrosis is a problem with the like, I believe it's kind of the airways are scarred and that essentially limits the amount that, that it can fill in the first place, but that just basically causes that particular noise. Cool. I think that works. Yeah. Sure. Thank you. Um I'm not sure if anyone asks you any questions. If not, we can move on to ab A um But yeah, we're right through it any questions? Yeah, sure. Go for it. Go after them. No. Is that ok? I understand. Ok. Um So first thing you need to know about abdominal examination uh is just to, again do a general inspection. You want to see the patients. Well, if they have any signs of me uh disease, um any other medical devices, signs, et cetera. So first you want to do a general inspection again? Now, always have something in the chart. Was there something in the chart? I saw something but now I can't see. I'm not sure. I don't have the chat open. Wait, let me check. I did, I did have it open but now it's kind of closed. Oh, let's come. Did you discuss pitting edema for cardia? Uh No, I didn't but I believe you do the acardia. I feel like I II might mistake, not put that in there, but you do check, definitely check edema, the cardia. Um So for abdominal examinations. So first you wanna again check the general inspection, you wanna look for biggest thing to look for scars. Um Now, I don't even remember exactly all the names of scars. Uh They're actually very difficult to remember, but generally all you, you just need to check to see if there are any scars. And again, they won't, they won't have them in the exam. Um It is probably not worth learning but the there are, there are certain, like there's like a kind of er, if there's like a little hexagon of scars that you could learn if you want wanted to. Um, uh, so one thing you need to look for particularly is jaundice in abdominal patients because uh they can have kind of liver or gastro Pao that can cause jaundice. Is there another question or if I? Oh yeah, that's fine. Ok. Er, and then, yeah, so that's the biggest thing and another thing is kind of masses if you see any masses on the outside. Do you see any her or anything like that? Um, so the first thing you want to do is check your hands. Um, so there's, uh, I know one of our lectures at 30 they taught us ABCD E so there's a, first, there's, well, actually, first thing you want to do is look at the hands. So you will tell them to look at both sides. You might have palmar erythema. Er, and that's uh kind of a cause of gastro disease. Uh uh Also, um, you will look for something called duplicans contracture, which again is another, um, can I think, I don't actually remember which disease it is but that causes, um, kind of a particular hand sign that I don't have a picture for. Unfortunately, I can look for it if, um, if, if you, if you have a question later. Um, so another, so what you wanna look for again is clubbing? So you wanna again tell to put their fingers, two index fingers together, you want it for any bruising cos that usually be caused by liver disease and then also a asteris. So you will actually tell them to, um, again, do the exact same thing, tell to put their hands out, cock their wrists back and close their eyes. And that can usually be caused by, um, er, particularly, er, hepatic encephalopathy. So, once the certain patients with liver disease builder, their liver fails enough, the toxins will essentially cause that sign. Uh and also something called uremia. When your, your um urea builds up, uh if they are for causes of clubbing, for gastro, it will be some, it will usually be inflammatory bowel disease or liver cirrhosis, but also gastric lymphomas just remember those three. Um Now, first, next, you wanna look at the eyes just like the previous exam and if they ask you is looking for signs of anemia and also jaundice, um because they'll usually caused by hepatitis or other liver diseases. Uh You wanna look at their mouth and that could use in gastro, that could usually be things like candidiasis, which is a fungal infection, uh or angular stomatitis, which is just an inflammation in the mouth. Um You wanna look at the lymph nodes uh but you don't have to examine all of them. There's just a particular one here, uh which um is called viral node on the left supra fossa. Literally here. Oh, do I have one, and I think that that is caused by gastric cancers if you, yeah. So if you go to the next one, um, so first you want, er, inspect, um, to see if there's any scars, any masses again. Uh, next you want to palpate the quadrants. So these are the, those nine quadrants that are, there are the main, um, nine quadrants so that you need to examine some of the times they say four, just do nine. That's, that's the sign of practice. So you can see it's right hypochondrium at the top, epigastrium, left hypochondrium, then left flank, umbilical region, right flank, right, like fossa suprapubic and left iliac. So first you need to palpate the quadrants. Uh You need to have a important thing is to have the patient flat. You need to have a flat bed. Um uh with inspection you, by the way, you're looking for scars, hernias. Uh Oh, another thing with hernias is tell patients to cough because if they cough um and, and their, their hernia will increase in size. Uh And I've seen that myself. Er So what you need to do is tell them to first, please lay the bed flat because at the beginning of the gastro, it's at 45 degrees. And the important thing is to lay down the bed flat, then you need to check for pain. You ask them for pain. If there's any pain, you don't start with that area. You always palpate in a different area. Um And then go back to the area last. If they say there's pain, there might be pain later upon finding that area. In which case again, you need to come back to that last. Uh And while you that and then what you need to do is essentially is kind of, you need to have your hand flat, but you need to just flex your fingers a little bit just to try and really like kind of feel the structures in the abdomen. Um And then do that across all nine regions while I'm looking at the patient's face and check for pain. Um And then again, if there is a bit of pain, then come back to the area. Uh you need to uh then do a deep palpation. Now, some people just do that with going a little bit deeper with their fingers. I personally do two hands that gives you a little more control. I was struggling with one hand. Um No, and that's just literally looking for like masses. Uh It's looking for pain. It's also looking for guarding. So if, if they have certain diseases that you, that you get like a rebound, um All right. And then next, once you've done that, you need to palpate the liver. So you need to start the right ileac fossa, which would literally be right at the bottom. You can see on the, on the right hand side and you need to er, tell the patient to take deep breaths, in, in and out while moving your hand. Like, so like this kind of like, really feeling inside for see where the liver is. Um, and that was literally be looking for something called hepatomegaly. I've never seen it, I've never felt it. But what you need to see feel is when you could feel the liver border it, it will kind of like hit, feel your hand, will, your hand will feel it. Er, once you get to like a certain part of the body, um er, and then, then you know, then you can stop, er, the other thing is to do it with the spleen. You start in the right iliac fossa and you need to go to the kind of left costal margin just here and you need to make your way across until you can feel the spleen. That's a little bit hard to feel. I would personally just go to the area and if you don't feel it, you don't feel it. Um, they need to do something called blot in the kidneys. What, what you need to do is uh essentially you need to put, if you were starting on the right side, you put your left hand behind the patient's back and below the ribs and just underneath the right flank. So just in the middle, on the right and you put your right hand on the anterior wall and then you kind of like push a little bit just to try and see if you could feel the kidney to kind of push in between your hands. Not too hard. Um, and you're not meant to feel everything. If you do, then there's usually a problem. It's usually fairly serious but you should say you shouldn't feel with it. It can be achiever. Um, next huge pap in the aorta. This can be very uncomfortable, er, for a patient. But what you essentially need to do is take your hands like this. Um And then kind of like you can put j really like squeeze your hands together just above the umbe umber like us and you should be able to feel the aorta uh as you might not be able to, especially if there's a lot of like er muscle fat over the skin. But um and it should be pulsatile. So you should be able to pulse and it feels in your hands. However, if it's expanse expansile and your hands move apart, then that's a serious, serious problem. You won't feel that. But d if they ask you what you're feeling for is a pulsatile but non expansile mass. Uh So next, what you need to do is percuss the liver and the spleen. Uh So for this, it will literally be er the same percussing. But when you start for the right elect fossa go up to where similar to where you f before with the liver. So just on the right fossa margin. And then once you found it, you then need to go to literally to the clavicle and go work your way down to again. And what you need to f feel for is if it changes from dull to resonant, so if it's dull, then it's the liver's there. But if it's resonant, then it's just kind of the other structures. But what do you feel? It's dull, that's the liver. They need to do the same with the spleen. Er that will actually be from the right leg, fossa, right to the left leg. So you need to go right across your body. So I appreciate I wouldn't. Yeah, I wish I could show you kind of like this. But if you look at the diagram, you'll be able to see what I mean. Um And that's the the main thing you wanna do. Uh Next you want to assess for shifting dullness. Um So this is essentially you start the umbilical region and you work your way to the left flank. You do, you cut across the left flank and then what you tell to do is roll the patient towards the right now. Um I say the right, but the important thing is is they might not know which way that is. So what I usually say is, can you please roll towards me? The reason being if you tell them to roll away from you and they fall off, you, you could probably get a lawsuit. So literally make that genuinely, it's, it's serious. Do not tell a patient to which way to roll as if you can't tell that they're rolling towards you. So to avoid all this cos I sometimes find it confusing always, whichever side you're doing, just tell them to roll towards you. And so that you've got you kind of even hold them so that you, they're rolling to the top rather than the other way. So tell them to roll towards you and hopefully that'll be fine. Then wait 30 seconds and then percuss again, if you becomes from, becomes a resident from Dell, then that's usually ascites. So you need to percuss at the start and then wait 30 seconds and if it changes then that's usually a cos it's ascites, there's fluid does move around, um, that's called shift and down. Um, right. So next you wanna do is, uh, auscultate. Um, so what you wanna do with this is with the bowel sounds literally, just listen in two areas. Er, you should hear bowel sounds, you should hear. So it's kind of like movements in the bowel. Um, if you heard tingling bowel sounds, that's what they call it. It's usually, uh, bowel obstruction. There's usually something up your bowel, if you ever hear anything that's, that's pretty bad. That's something called an alius. That's usually, uh, uh, another type, not the intestines, basically kind of stopped contracting. Um, uh, that's a serious problem, but you won't hear any of that. Oh, another thing is listen for bruise. So listen over the aortic and then the renal and the renal will literally just be, uh, later above the umbilicus and listen just above the umbilicus. So if you're listening in those areas, you'll be able to listen to a bruise. Um, and that's us usually things like an aortic aneurysm. But again, that's the serious problems that you were in, but you just need to listen to other areas. Uh, oh, and last thing is f for deer again, uh, in that, uh, in the legs. Oh, and you? Sorry, I forgot to mention that diagram there. So you can see that the fluid how it's moving there and it becomes dull, be, um, because the fluid is moving there for the Y Yeah. Um Yeah. No, no, I II think I can add to this a bit because we were actually doing update examinations right now. Uh, and you, you're pretty much just spot on ups, um, especially with the ba of kidneys. What the, the press was saying was like, um, you don't wanna do too much, right? So you wanna, you wanna put your left arm over? I just wanna try and flick it, just flick the kidneys. Yeah, blow it up. Um And it's good if you don't read anything, as I mentioned. So, um, yeah, yeah. So, uh, yeah, that is a good refresh. Thank you. Um, any other questions in the chart? Can you see any? But also with the, the petting edema, by the way, um in terms of a cardi a cardiac examination, uh you do have soft pitting edema quite a bit. Yes. Um but later on with like sort of right cardiac failure, it does become hard. Um So that's one of the signs of like soft pitting edema. Um But yeah, I in the cardiac sense. Um yeah. Um yeah. Is there more any questions about that? Mhm. I do. I is my favorite pass me but yeah. Yes. Uh go keep skip, skip a couple, skip a couple of the next one and then the next one. Yeah, there we go. Ok. So, so that's the end of the examination bit. Um which is the main part of this. Um I've got a little bit now on EC GS and spirometry, but again, it's only like a very small amount because they don't have time to do all of it, but I'll just cover basics in about 10 minutes or so. Uh And then if anyone has any other questions or in the future, maybe in the future, perhaps we could do a more specific session for that. Er, because I think that would be a bit better. Yeah. Uh so in the example, what does normal bowel sounds sound like? Oh, it's hard to explain it. It's, it's more like, you know, when you like hear like kind of gurgling. Yeah, it's, uh, yeah, I don't know the exact term for it but if you, if it sounds like something you might feel that, you know, if, like, you, you feel hungry, it, it genuinely sounds something like that. Like a, another thing to obviously, um, with certain things, like taking blood, don't do that on your friends. But another thing I found is a lot of these, if you practice on your friends, uh or your colleagues or whatever uh kind of it, you do hear the, you can hear what normal things sounds like. Um When you examination, what did you kind of? Yeah. Yeah. So recently we did do this etcetera and the main thing to look at is essentially um pathology wise with regards to sound and everything. Um uh Of course, with everything is a AAA so just a normal aneurysm itself, that's the main thing they're looking out for, but normal bowel sounds, they, they, they, they, they're pretty much what you like hear when you, for example, like you're hungry. OK. So it's the same thing. It's like it's low pitched, it's quite uh a gurgly kind of sound and they're intermittent, they happen around every like sort of 10 seconds. Um So, yeah, that, that sounds, is completely normal and often that is overpowering noise in that area itself. Um As where I mentioned, um the main other thing is looking at brewery and stuff. So you wanna start off at like a, above the umbilicus itself and then of course, you know, anatomy, you know, the sort of a aorta, you know, the C DAC trunk s ma I ma um, try and follow that pretty much on the left and the right flank for the renal arteries. Um, but other than that, there's not much sort of, um, sounds, but like with the B sounds, it's like, honestly, it's just like normal gurgling. It's just very low pitched, it quite, um, intimate and it's on and off. Um, and, uh, yeah, you know, if it, if it's quite, uh, a high pitched kinda, I'd be like a bit worried, I guess cos you don't really want cos it might be just a sort of gas or like, yeah, um, fluid maybe. Um, but yeah, or, or an obstruction often. Um, or if it's like a sort of, I don't know, uh, if you got absence of bowel sounds, I think that that's the biggest thing if you, if you hear something you said Ileus. Right. Yeah. And that's usually if you don't, if you don't hear something, uh, I obstruct, that's usually when Paracels stop. So it's literally I stop but obstruction, usually a tinkler kind of high pitched sounds. The lower makes sound a bit more normal essentially. Does it help? I hope he does. Yeah. Is that right? Shall we go on to the next bit? Yeah. Go for a good for, um, uh, yeah, there we go. OK. So essentially, so I've only just got all the basics of G and just kind of showing the parts of CG. I'm, I'm feel like this, you probably would have covered anyway, but I'm just going quickly over. So with P waves, I'm just gonna go over the, the cycles and what they mean with the heart. So P waves is literally atrial prier. So when uh literally the atrial um uh when essentially it starts contracting. So that wave electroactivity is called depolarisation. Uh The pr interval is uh as you can see in the orange, there is um literally the time for activity between from when the atria contract and then the ventricle starting the PR S is literally the depolarization of uh essentially the ventricles. So that's why it's the biggest part because that's when the ventricles kind of contract the most uh well, they contract more than the atrial. So that's why it's higher. Sorry. Uh The ST is literally between the deprival and rep prior of ventricles and the T wave is a rep prior so that the rest thing. So just like the way you might have seen in uh the cardiac cycle with blood, it literally follows but not quite the exact same. But I in, in terms of like sequence, it is very similar to the actual contraction of the heart. Uh wo max one uh essentially. So with um the heart. So you've got different with the E CG you've got different leads. Er, so there's 12 leads and I haven't got a diagram here but you've got the different, there's that show, it's 10 leads and that leads to kind of, of 12 different parts of it. Uh, 12 different parts of the E CG. Er, and there's kind of six, there's six on the chest and then you've got one here, two here and then two in the lower part of the body. Uh and those 10 leads kind of er lead to before you get an E CG. Uh and different parts of the heart will be represented by different leads. So the inferior part of the heart. So that'll be like the right uh uh coronary artery mainly and also the left side, but mainly the right. So no, that the right, we leads 23 and A VFA VF. The A V lead is kind of like not real leads. Essentially, they're made because of like complex mass. But the, the real ones are uh are the other ones. Er and then lateral will be literally things like uh the left circumflex artery. Er And also um yeah, mainly that and that would be one A VL five and six anterior, which would be the, the main left anterior descending artery is V VV four. And then at the other part of the proximal left anterior descending artery was the V one V two. If you go to the next one, did you one Uh OK. So this essentially, um, I've just got a couple of example, EC GS here again, I'm not going too much depth but this is, uh, is issue. Do you know what this is? Oh, you're testing me here. I've never done this before. Ok, good. Um, I II don't expect you to know, but I had a feeling you might because this is one of the easier ones you'll see. Is it OK? Cool. All right. Do you wanna direct me towards where I should look at first? Oh, yeah. Yeah. Oh, so if you, so there is a system of looking at EC GS, but the one I've put in here are kind of like ones for the couple or two I've put in here just again, they're just introductory because if you want to have a session eight or whatever but is to look at particular pathology. Um, tell, so tell me which lead to look at. Ok. So I, if you look at leads two and three, tell me if you see there's something different about them. Ok. So I can see that the, you've got, well, you got one like, do you have, do you even have AP wave? Uh OK. So the QR S complex is quite steep and then there's no sort of T wave, right? Or is there ST elevation? Sorry, ST depression? That, that's, it's ST elevation. So I elevation myocardial infarction and you can see mainly what leads 23 aVF. Right. Uh, so leeds, 23 VF is inferior. So that'll be at the right coronary artery stemming essentially. Or myocardial infarction in that area. Um, and sometimes it can be really nice and give you ones like that and yy, you can usually be able to identify it fairly easily. Er, next one, I think I've only put two in here actually. Um, this one's a little bit harder. Um, essentially what you'll notice about this is that there aren't many, there aren't many P waves at all. In fact, there's nothing, er, and without P waves, it's usually one or two things, atrial fibrillation or atrial flutter, atrial flutter is usually a saw tooth pattern, but this is literally just like it's very flat, there's no P waves at all. Um, and also what you can tell is this irregular, it's called irregular, irregular because you can tell that the space in between the, um, different QR S complexes are not right. They are completely irregular. Er, and that's another way to tell. Er, unfortunately I haven't like gone through it exactly properly. Um, which II wish I could have done it in the hour. But, yeah, er, this is all I've got EC GS, er, if you go to the next one, I've got a bit of spirometry. Um, so I've just got a couple of basic spirometry here. A spirometry is essentially a test to, to test lung function by testing the volume of air that patients are to breathe out after breathing in a maximal amount. Um The main way to the main reason for it being done is the difference between restrictive airway disorders and obstructive. Obstructive is things like CO PD asthma. And that's usually kind of like uh narrows the airways and causes um kind of problems. And then restrictive is usually like things like scarring. And that means that it, the reason it's restrictive is because scarring kind of restricts the filling up in the first place. Whereas obstructive is, it means it, it's obstructing the flow, which is a slightly different thing. Um, but it's also used to do for severity of diseases because, er, if your s if the spiry results are worse, you know, over time and you can tell the disease is getting worse or AC O PD is kind of declining over time. Um Now the measures are mainly F EV one, F EC and FE one over fe CF ev. One is just the volume excel in the 1st, 2nd after deep inspiration. Um Four F EC is four spices for capacity. That's the total volume of there that it can excel in one breath. Now, the ratio of those is um essentially F EV ones. So how much they can breathe out in one second over the total volume that they can breathe out. Um And then essentially that is used to for inform, um that, that is used to inform like the the level of pathology if you go next. Sure. Um So to assess um the problem here, there's two things to look at in particular here. This is for obstructive disease. So this will be something like CO PD asthma. There's two problems with this one is that once cos it's obstructive, the total fu er the total F UV one is actually reduced. So the total amount you can breathe in one second. Sorry, the total, yeah, the total amount you can breathe in one second is reduced. And also the total amount that is breathed up over time is reduced. So that total F EC that's the total amount but not so much. Uh And then the other thing to notice is the F EV one over F VC ratio is reduced. So what I mean what I mean by that is if you can see in the red obstructive, the total amount in one second that they breathe out is reduced compared to the normal picture. But the reason I say the ratio is reduced is because the total amount that they can breathe out is still similar but because they can breathe way less than one second as their, their lungs are less powerful if that makes sense, right? Uh And the cause of that will be literally see things like CO PD asthma mainly uh uh cystic fibrosis as well uh an emphysema. So if you go next, er yeah, this is the last line up actually. So the main thing about restricted lung disease is the reason why the amount is really low. So, you know how if you go to the previous one, the, the red line was pretty close to the red, the green line, that's because the lungs still fill up. But when you breathe out, it's, it's much harder to breathe out because of the obstruction with the restricted you go next, you see how the total volume is way reduced. That's because the restriction in tell the scarring, it makes it difficult to do it to fill up in the first place. Um And that means that this becomes lower, but also the FV one does um reduce. But the main thing to notice is that the FV one over F EC is normal. Now, what I mean by that is that because um the, so you, the amount you expel in one second is reduced as well, but the ratio stays the same essentially because uh the F EV one and F EC have reduced by the, the er s not same amount but almost the same amount. So that means the ratio is the same or is normal, which is above 1.7. But the key thing to notice is that um essentially the, the, so if you go back this year, I feel like I'm doing this really bad. The difference in terms of how um the difference between the normal and obstructive hair you can see in one second is greatly reduced and obstructive. But if you go next and restrictive, it has reduced. But to a lesser extent, that's the other thing to notice. So that's all I have. But, um, if anyone has any questions I'll go back to that dodgy screen. That was really dodgy. No. Um, thank, thank you so much Rohan. Uh, I appreciate it. Uh, it was a great session. I learned a lot as well. I was like locked in the all the time. Um Yeah, just recapping at the end as well with the with the with the restrictive obstructive diseases and everything. Um So like wait an example of restricted disease without what like pulmonary fibrosis and ok cool. And then the um their their ratio for restrictive is like ok. Right. Yeah, the ratio is it's really really low, it's normal which is above 1.7. So in both cases in this case you have fe one FF ec reduced but the ratio stays the same. Ok, fine. That makes sense because it's not because it's a different disease process, right? Ok cool. Um does anyone else have any questions? Yeah, please do. If you have any questions, please just pop in the chat. Uh we'll we'll we'll try to get them sorted. Um Do you think you can send out the link as well for the powerpoint? No, no, no the uh the QR code because I didn't put it. Oh, Right. Right. Right. The, the QR code. Yes. Um, but you could put as a, yeah, I'm, I'm gonna put it in the chat now. Uh, there is one thing that we want you guys to do, please. Um, this can like be your pathway into the, the British Indian Medical Association, um, to an extent because you are a family we are talking about. Um, so, so II didn't mention at the start. Um, I'm pre school officer. So um I work with a couple of my uh other friends from UCL um who are like fourth years er in the preclinical team. And B er Boran has very kindly sort of helped us out with this um preclinical er talk. We have more coming up soon as well. We have like a hematology and genetics, one for freshers and second years. Um 11 of them will be that by me, the he hematology, one probably I don't really like genetics. Um But we'll do that at the end of this uh sort of month. Uh And then we'll get started with some um cardiology, a whole series I led with the UCL team um uh next December. So please do join for that as well. We'll find out the links whenever. Um and there was one second. Now I'm gonna try and find uh the link to, to, to, to, to send you guys. And also um actually one of the network officers is here as well. So you will, if you keep an eye out there will be hopefully some of that soon. Yeah. BS is also part of the beer uh committee. Yeah, I can, I can show the slides. Um, the thing is, well, I can't really say the QR code on this thing. Oh, wait, surely I can wait. Hold on a second. Where would I share? Share the slides? Ok, hold up. I'm gonna put my screen. Wait. Yeah. OK, guys, if you can please scan this quickly. Um That would be great. Uh Oh yeah, I've got a lot of stuff going on. Yeah. Uh Someone was asking if I could share the slides. Do you know how I would do that on here? I'm not exactly sure. Yeah, we, we, we will send them out on the Beamer community, the the whatsapp chat afterwards. If you're not on there just like uh direct contact myself or directly um by email. Yeah. Yeah, you can ask me as well. I can even if you can put your email on the chat, please. Yeah, that's fine. Yeah, if anyone directly, I can also send them like sure. Um But yeah, guys, if you can please the scan this, I'll leave it on for like a minute more. Um But yeah, please do come to our events. Uh There are more opportunities to get involved with in be a this year. Um We'll have a networking event and our conference coming up next year. It should be a great platform for you guys to get involved. Uh We'd love to have you apply for committee positions next year as well with researching networking, all this stuff going on. Um And we really appreciate your support with these sorts of lectures as well. If you do wanna give your own lecture, please do contact us. Um And we can try and get that sorted as well um in any sort of subject that you feel like you're confident in. Um But yeah, I'm gonna stop sharing now uh just to finish off. Thank you so much. Uh Ver well, I appreciate it. You're, you're a very busy man uh as 1/5 year as well. Um And hopefully I do reach that stage one day if I don't drop out. Um But yeah, well, these will help you. Yeah, I'll come to these be editorials. Um But yeah, no, great. Uh Thank you so much for that a lot. Um If you have any more comments or any more questions, please run back to us. But other than that, uh we will see you soon. Great bye. Thank you.