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Taking a History for Hip Conditions for Orthopaedic Exams
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Taking a History for Hip Conditions for Orthopaedic Exams
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Language: EN.
Segment:0 .
Good evening, everyone, Thanks for joining and sorry about the delays this Francis teaching session from the farc, a splinter group. The presenter today is Mr. mavela. I'm sure you all know him. He's a consultant, surgeon and his senior mentor from with this group from the outset.
He's also a director of a very famous FARC course, which I've just shared here on the screen. I'm sure you guys would want to probably look at this. It is very well attended. And he has been running it for many years, very successfully. And he also has run previous sessions here on the examination, which have been received very well, and therefore we had the 100 for more clinical examination sessions.
And we have with us today also some of the other members of one who will act as the co examiner today. And we have also David, he's one of the senior mentors supporting decision myself. And for us, I'll be moderating, admitting you guys and shorting out participants and candidates. So I just want to say, obviously running an interactive clinical examination, teaching online as a webinar is very challenging task that you have prepared and spent hours preparing for without your active participation.
But I encourage all of you to step in and take part. That is candidates who took this very useful and assisted them to pass their exams and decided to run another one. So if anyone wants to take part, please either write express that in the chat box or raise the hand symbol next to your name and I will choose you to come forward. But if no one comes forward, I will have.
I'm afraid to pick people because it's essential to the successful running of this session to have active participation. And just that, we will respect, obviously, your privacy and participants participation. The performance of participants will not be recorded, and if recorded, it will not be published. It will be edited out.
And so there's just a final reminder, if anyone wants to CPD certificate for attending you entitled to one nice gift from the Royal College. So please contact me directly to get one. And without further ado, I'll leave you with Mr Malik's mavela to start the session. OK, thank you very much for us, and Thanks to John and David for being there.
Like I said, you may have attended a knee examination. I'm not sure if us was it about six months ago, maybe around that mark. Yeah, about eight months ago. Yeah, eight months ago. And we did two sessions. I think it takes. So what we are trying to do today is hip. A lot of the things may be repeated again, but it doesn't matter.
As you know, lower limb is vital for your intermediate case and as much practice as you want or you can get is good enough. So the way we do it and we'll start off in sorry for a delay, but it was very important that we do. This is we take our time. There's going to be no rushing of it. At the same time, it'll be completely interactive. I want every one of you all to imagine, and it doesn't matter what your performance because we just want to know how you present and how you talk.
Shawn will be my co examiner. Imagine that it's your let's start with being an intermediate case, and as you know, in an intermediate case, will be 5 minutes over history, five minutes of examination and 5 minutes of discussion, all in front of the examiner. So when we start the session, let me put a scenario to you that I got two of my registrars who have kindly taken their time out to do this. One of them will try to angle the camera at the best angle.
But please bear with us. Like I said towards the end, you are you. You finish in five now. I think we have to critique you. So I must say, and I think Shawn and David will agree that you are where you're talking, your clarity of your speech, your relation as to what you're saying is excellent. I agree with everyone, Shawn and David.
Good report. Yeah, thank you. So good rapport with the patient. So that's fine. Don't change that. Let's just now concentrate for everyone in the group on how to take a correct history, because please imagine and understand that the five minutes is critical for your marking.
You can't say that I'll do a good examination and 5 minutes of history. Now, in any history, this could be lower limb. It could be upper limb. Please understand. A we want to get to a diagnosis of what it could be. Abdullah Yes. And second, we need to know how bad it is for the patient. These are the only two things we want from our history.
So I just put up. So hence. Initially, for everyone, I wanted to introduce yourself like Abdullah did, so everyone's going to say that, say I would suggest, give you a surname as Mr. or doctor, whatever your surname is. But I'll leave it to you if you want to feel more comfortable. The first name, but you don't have to. My suggestion as being and seeing hundreds of people coming through is usual.
It's more professional to use your surname. Just say this, Mr smith, is it all right if I take a history and examine you? So in other words, you're taking implied consent. So you're saying that I want to do this? Yeah don't go on giving a long thing that I'm one of the candidates. I'm going to do this. I'm going to do that.
Just say, is it all right if I take it history and examine you a bit like you did? So very good. Next start. Very often you'll get a letter saying that this patient got left hip pain, Abdullah. So if you do get that, I would say, take that as a good sign and say, I understand you're sitting here because you have problems with your left hip, you know, so it means that you're constantly taking control of the situation that you realize the GP letter or what the examiners have told you.
So once you do that, try to focus what you ask was good that you say it. Tell me about your left hip. I think we have to start with that, and let's hope that the patient says that. Yes, I got pain in my left hip and the patient says it's 30 years now. Abdullah, he says. 30 years.
Do you think anyone has waited 30 years to see any of us? None of us are so important. You take 30 years to see someone, right? Abdullah is that correct? Yeah so therefore, try to say yes, I will come to your 30 year history, but please tell me what has made it worse. Now Is it worse over what to try to get to the present history? Yeah so everyone.
Try not to let a patient give you 30 years of history, otherwise you finish the exam the next day. Yeah, you have to try to do it and say, yes, I'll come to it, but tell me about your present history. Now the present history Abdullah is one year, so I ask him, yes, sir. Has it been worth over one year and then ask him, now I want you to ask him. Mr smith, when it started one year ago, did it start by itself or did it start with any history of injury?
Let me see how you ask him that. Go ahead. So how did this started in the last year? Mr smith, don't ask him that he doesn't know what to expect. You have to be clear, Abdullah, you know, he'll say, I started by I, you know, I had a fight to my wife, but that's not the answer of why. Or, you know, I had a fight with my neighbor. I was really upset.
You know, you don't want that answer because they didn't give you that answer. You have to know whether it started with very clear. Did it start with an injury, Mr. smith, or did it start by itself lost? Then so did it start it on its own? Or there was an injury that caused it myself? Oh, it started on its own. Yeah, so that's why I'm so now.
You're very clear. The onset was insidious. All right, Abdullah, now we move on. In the next year, you need to know whether it's become worse. It's become better. So ask him. I wanted to ask him. Mr smith, over the one year, has your pain become worse? Has it become better or are there some days worse, some days better?
OK, that's the answer you need. Ask him that. So Mr. Smith did start. Did the pain is the same or is it worse or improved? It's been worse for years now and since last year. It's getting worse. So you can't you get that answer now that is becoming worse, right? So that's your second thing.
And so you got the onset, you've got the duration of one year, you've got the progress, which is one year of becoming worse. Once you clarify that, Abdullah, I would like you to do ask you didn't. What you didn't do is you need to know very clearly any part of the body. And this is for everyone. Please don't accept the patient's word for shoulder, hip, neck.
They don't know whether or not they know where the hip is. What question do you want to know that it's a hip which all of us in the room are orthopedic consultants like yourself and myself mean? So when patients says hip pain, which part are you wanting to know where the pain is? Which part of the body? So where is the sight of the pain? So in a hip way, the sight which you are concerned about the groin pain, correct?
Fantastic so let's not use the word hip to him. Yes do you have any pain in your left groin and classical of that pain anywhere in the body now? You have to ask for referred pain. All right. So you say yes, you have pain in the groin? And does it come down to your front of the thigh, to your knee? Is that classical of hip pain?
Is that correct? Yes yeah, Yeah. So you ask him that say he says that? Yes, I got pain in my groin coming on it, and you are very clear you're dealing with the hip pain, which we know as orthopedic surgeons. Yeah if you commonly ask if you go to a shopping center anywhere in the world and you ask people where the hip is, where do they point to most of the time of the outside?
Fantastic, they point to a traject area. They point to their flank, they point everywhere else, which we know is not the hip. That's why I'm so particular. And the same thing with the shoulder you don't take. They would ask what you want. Yeah, that's what you do from now onwards onwards. Next, we go on to we used to rule out, I want you to be a safe surgeon.
What have you do? A hip for one of my patients as my colleagues and the patient's problem is, are back. Do you agree? It's a common scenario? Yes so have you demonstrated to schwann, who is my senior examiner that you've been safe and you've asked for the back? You agree you've not done that, you know, ask him, Abdullah, how are you going to root at this moment?
Once you've clarified the growing pain, you're going to rule out for my senior examiners that you're convincing him that you ruled out a backache. So ask him how I'm going to ask him all the back. And then for us after this question, do you mind switching to someone else and then someone else can have a Yeah. Mr smith, do you have any problems in your back or in your buttocks?
No, it's mainly the greens and any pain in the back of your thigh radiating down to the toes. No, Abdullah, fantastic. So this is where now you're very clearly asking correct questions. If he says back at buttock is one and the second question, does that pain go down the back of your thigh to below your knee with pins and needles? So this is classic of your symptoms.
I want you from today to write down classic symptoms of all parts of the body, which is going to ask as a direct question to patients. All right. So shoulder pain? Yes. Does it come down that aspect of the thigh? Sean and David will use some other suggestions. You know what I mean?
Try to prepare those in your mind and what's coming out of your mouth are not my mouth, not your mouth. All right. Yes thank you. Very good. Thank you. Very happy. Yeah well, I'm sorry.
Could I just the very opening line about what brought you here today? It's the classical thing we all do. I'm just as guilty as anyone else. But in the exam, remember, these people are volunteering their time. They're patients, they're volunteering their time, they're coming to help us. And often they're bored.
And they might say something like, yeah, an ambulance brought me or a car brought me, and that puts you on the back foot straight away. And they're there. They're there to help you, but they'll make some throwaway comments which will make your life difficult. Take control of the situation. The GP letter is there. It says the patient is coming with hip pain.
Say the opening line should always be something along the lines of hi, my name is Shawn Henry. Thank you for coming today. I'm one of the candidates. Your GP doctor says you're here for hip pain. Can you tell me more about your hip pain? You can start off like that, or you can be very direct about specifically the pain that they're feeling, but don't do opening lines like what brought you here?
I know it's a classical thing we always say to try to avoid that. Yep John, thank you very much. I mean, it's one thing exactly what I'm marrying to please all this new fangled way of being open and being things is not going to help you because the patient will say something like one thing which is not going to help you at all. And you don't want that.
So please, I completely agree. Perfect thank you. I didn't say that yet. I think she's on the right. Let's thank the patient for being here. As well as saying yes, I understand hip pain and stick to it. It's much better to stick to specifics. Yeah all right.
Who's next? Next, sheriff? Yeah, come on, Sheriff. You come in. This is your intermediate case, and here are your examiners. Sheriff Yeah. Can you hear me now? Yes Yeah.
OK, great. Thank you for getting on. Sherry flo, let's carry on from where we are. You've done your duration progress. Now you want to know that. What's your next question? You know where it is. You've classified it as no back pain. What's your next question going to be?
I'm very happy the way out in the question. So don't change that, however. Sheriff, what do you want from the patient now? Now that we've gone to this stage, you want to clarify how bad it is, right? The first was trying to get to a diagnosis more or less. We know it's like, Sean said, we are homing in on that. It's hip and groin. You need to know how bad things are for his pain, right?
Is that right? Yes, you need a few questions to clarify that. So one is, rather than lying on that side in your mind, if someone lies on that side, what is the clinical diagnosis most of the time, if he has an issue? Intra operatively bas status fantastic. But we hope that the patient doesn't have traject bas status because, you know, that's one of the most difficult and difficult and most unpleasant or unsatisfying things to treat.
And would that have groin pain? Unlikely, right? So the question you want to ask is Knight pain at night? The don't ask about sleeping on that side, I would say, ask him, Mr smith, does the pain wake you up at night? He'd say Yes or no? OK, that's one. Next, ask him, Mr Smith.
When you're watching TV, you get paid. What is that called? That's called rest respin. It's not called sitting. It's called respin. In other words, it's bad. Number three, Mr smith, when you get up from a sitting position, does it give you pain if you agree? Many people say, I can't get up.
Is that correct? In real life, Yeah. Yeah so that a thing they're climbing. You agree. Stair climbing is important that he finds difficulty climbing stairs due to being in the left hip Sheriff. Yes Yeah. And the fifth will be walking distance now, he said.
Shops now, unless you live with them, which are unlikely, you're going to live with Mr Smith. You don't know where shops are. So he said, shop and you let that question pass. So Sheriff, take control. Me and my examiner also don't know where he lived. So you say yes, I understand you can go to the shops in that. Thank you very much, Mr. But is that in how long now for everyone?
Most people and most patients cannot give a correct idea in meters, so just stick to time, say Mr Smith. Is it such that in how many minutes you have to stop because of pain in your left? To ask him that and he will answer you, gives you ask him exactly what you want to know in minutes. So when you walk on a flat surface, how long do you walk 10 minutes before you have to stop? Because of me clarity in the left hip?
Because patients? Yes, the doctor. But my Antoine is my senior example. Pick up that, you know, this patient has a very, very bad problem with his right ankle. And that's what's stopping him. You know what I mean? So be clear the left hip? Yes ask him again.
So how long? How long can you walk before you have to stop because of the pain in your hip? About 10 minutes, not more than 10 minutes. That's right, so, you know, you get an answer now. 10 minutes is a good answer that yes, I will offer him a hip if everything fits, you know what I mean. But if he says I can walk 45 minutes, then unlikely, you get a good answer.
So the way to remember this for everyone is remember an old man sitting and watching tv? That's a recipe. All right. Imagine the old man gets up to go to sleep, so he picked up this whole pain from getting up. Imagine he's walking through the stairs in his house. What's that called? That's your walking distance that goes up the stairs.
That's stair climbing. And he sleeps at NIPE to the 5 points of severity of pain have been covered. Right? so don't. This is the best way of remembering it, and I want it to go very quickly, but very precisely to get the information. You can remember it. You can remember it by man sitting and watching TV, and he gets pain.
So remember, you would ask him and that's resting. Then you're going to imagine that you're going to sleep. So he gets up to start walking. And that's pain when getting up or sitting positions and say, messersmith, you get pain when you get up from sitting position. The third is he walks to his stairs and that triggers your mind to talk about the walking on a flat.
So, Mr smith, when you walk, how many minutes can you walk before your left? Hip pain stops you? Then he goes up the stairs. So yes, when you climb stairs, do you get pain? And when he sleeps at night? Yes do you get pain at night? That's the way I remember it. So I never forget 5 points for lower extremity and use this for back, hips, knee, ankle, whatever you want.
Yeah, happy with that. So I thank you. Very good tip. I use slightly different. I say, can you get up off your chair? Do you have pain when you're sitting down and you get up, you stiff and difficult to walk? Do you have difficulty going up the stairs to put on your socks and change your clothes to come back down, to go to the shops?
Any difficulty doing that? That, to me, reminds me of pretty much eight of, sorry, six of the questions that you need to ask, which are not to do with the intensity of pain in the ass. Thank you. That's a good way of adding on two more points. I'll remember it for next time that we'll combined it. But what I want to tell all the candidates is that we are both experience, but we still need triggers in our mind to get it right, right?
So it means please remember that taking this exam is not something that you can go to. All the courses, see patients, it's what comes out of your mouth. So please practice these phrases. Yeah, that's that. So now you finish that sharif, and we'll finish one more question with you once you finish that. What do you want to know?
You've got your pain. You've got to intensity. You've got your socks and shoes, getting it out of a car, which are classical of hip pain. Then what? What do you want to ask then? I want to ask about his job and any hobbies or activities which are typekit before that, before you go to back. Hobbies my best guess for you is to try and do.
Another heading is other joints and fast hip history. So let's stick to past hip history. Yes and then other joints. So in past hip history, remember he told us he's the same patient. Remember, he told us that he had operated in childhood. Now, say that, Mr smith, please tell me when you were born, did you have any problems with hips and knees? Ask him that.
OK, Mr smith, when you were born, did you have any pain in your head for needs? Did you have any problem for me? Yeah, I had a problem. The hip? Yeah, I had a problem in the hip. My parents told me that I was limping for most of the time. OK, so that's one. Then next, say then say, when you were younger, did you have any operations of on your hip and you say yes?
When I was seven years old, I had an operation done. So you can ask him that and you can say, yes, I had the metalwork removed. Let's that. Yes, you got that answer. So every patient, you're going to ask any problem with your hips and knees when you were born. The second thing you ask him is any operation to your hips and knees in the past.
Third, you can ask any fractures of your pelvis, femur or tibia. I want you to ask every patient that to ask him that exhibit. Have you ever had? So have you had any fractures in your leg? No leg is something which his leg maybe is toe. You want to know pelvis. Most people know pelvis. Most people know femur. And most people will know tibia.
And you can still see it. And within five minutes. So I'm not, I'm not making you take longer, but you need this answer rather than later. Forget him again. Did you have any great thing, your pelvis or your femur or tibia or your tailbone, rather than femur and thigh bone and leg bone? No, not that I remember.
Yeah so that's a good point at all, Sheriff. Right, thigh bone, leg. So that's what you asked for, fast hip history. And then you can ask, do you use any painkillers? And do you use any crutches or sticks? So in other words, I don't like asking what you're taught in many courses about. Please tell me, aggravating and relieving factors. The reason I don't ask this is aggravating factors will not help me because the aggravating factors may be something which is like I can get into a low car, but I'm not going to do a hit because you can't get the local, you know what I mean?
I need the answers and relieving factors. What you're indirectly asking is what treatment have you had? So the best way of putting it is in the past hip history and for everyone, try to keep this for past knee history, for spine history, all the same, you know, the headings are all the same. Complained how bad it is. So I'm just recapping again its present complaint. How did it went?
How did it start? When did it start? What is the duration and whether it's worse or better? Next, go on to where is the site of the pain and ruling out referred pain, right? Third is intensity of pain with all these questions, which with a combination of mind and tshwane's about how bad it is. Fourth is past hippie streak, which we've done, and now we go on to other joints.
It tells me you told me that your other joints replace you say yes, I had my right hip left knee. Is that a good head injury? Happy with that headings. Yes and now you can Sean and David, if you to add anything. And then we can move on to another candidate for us. Can I just there's one known question the candidate asked about the difference between pain and chest pain and what does it mean?
I think my take on this is that for, you know, for the exam, you want to take the lead and the control of the situation. So the question I would put to the patient here is does the pain wake you up from sleep? Fantastic very good. I agree. And all of this and what does it mean? What does it not mean or do you want to do is how is the pain restricting the patients daily life?
We're not inquiring about possibility of infection or tumor here, because that would take another line. You just looking at its effect on daily life. But just a simple question does the pain wake you up at night? Yes or no? Yeah, that's just my take on this. Very, very, very good point. And let's stick to that without a doubt for everyone.
So the point about so the question is being asked, how does this differentiate between pathology and infection? Correct but at this stage, we're not trying. These questions are not there to confirm our diagnosis. These questions are there to score this patient on what we call patient related outcome measure. In this one, it's the Oxford Hip Score.
If a copy of this on the telegram just now, so you guys can look at it later. So these are differentiating questions in terms of scoring marks which have been validated to study the severity of this patient's pain. We're not at differential diagnosis. And as for us said, my pain is a specific thing that wakes the patient up at NIPE and at rest.
Pain is a pain that when the patient is sitting down resting, this hip stiffens and he gets pain. These are not to do with differential diagnosis of pathology such as Kessler. Excellent yeah, that's Yeah. So and all we are trying to get at is the severity for four lesions that we need to know of. But more importantly, just let it come from your mouth as to what your phrase is going to be, which is correct.
So now we move on because we someone else, we're just to end this. Thank you, Sharif. Well done. We move now to Joey. Hi, Joey. Hello Hi. How are you? I'm fine.
Thank you. Do how are you? Well, you are the next candidate. We have two nice examiners here. Come in. This is your intermediate case. Yep so you're carrying on with the same thing. Imagine you're carrying on now. You've asked this, you're going to what are you going to ask next?
So you've done your security, you've done your past other joints, you've done your past hippie streak. Mm-hmm So I will proceed with. OK finish that because you're so. In other words, let's agree with everyone that once we finish the hip or the spine or the knee and peace, take this as a generic good history taking which one and for us and David to give you tips on.
So Joe, in your mind, once you finish that part, we all agree in an intermediate case, at least we have to take a history of what we call medical history or social history. Is that right, joe? Is that what you wanted to know? Yeah so I always feel a mind triggers up to something. So once you finish that you need a trigger to say you're finished with your hip and going onto something else.
So I ask at this stage, please everyone ask allergy. All right. Allergy is quite an important, I would say, when Ashwin and David and for us, but I think it's a very important question. So the allergy I need to know is, are you allergic to any drugs and any metals now? It's a controversial topic to know whether, but I still ask it OK, because we're using skin staples, you need to know that.
So let's ask everyone from today onwards, Mr smith, are you allergic to any drugs or method? And that's breaking the ice moment. It triggers your mind that you're finished your part and going on to a medical condition. Joe? yeah, yeah, OK. Now when you go medical condition. Please, you can ask what medical conditions you suffer from, but once again, I don't know what you are, and for us, in David's view, is but 1 May agree with me that if you ask that you'll get a 10 minute rant on something of his medical conditions, which you are not really helping you as a hip surgeon, what you need to know is with your consent change and you will give him a high risk factor for my hip replacement I'm doing.
That's right, Joe. And secondly is whether he merits a hip replacement or is other medical conditions more important, which is stopping his mobility? The anesthetic assessment is not for me or you to make. We are not anesthetic consultants or police, right? So all I ask, therefore, is let's ask the questions that Mr Smith. Do you suffer from any diabetes?
You're getting diabetes? I need to know because my risk factor will say, sorry, you are at a high risk for infection. You agree with that, Joe. Would you not tell him that? Yes, you ask diabetes next. You have any take medication for blood pressure. Why? because uncontrolled or fragile off label blood pressure is contraindicated for elective surgery.
You agree with that, joe? Yes Yeah. So your last blood pressure in tablets and is it under control? Number three, you can ask him. Have you had any recent heart attack or stroke? Do you agree you do not do your hip or knee for one year after a recent heart attack or stroke? Yes we're going to ask him that then when you ask the two questions for breathing.
It's a slight. Lined flat is not the issue. You want to know whether you do a hit or not do a hip. So the question I ask him is as follows Mr smith, you have listened to what I'm saying. So Mr smith, you have problems of breathing, but you get you get breathless. If you get breathless. Yes yes, Yes.
So what stops you when you walk? Does your left hip pain stop you or your breathlessness stops you? And if it's still active now, you're clear that you offer him a left hip to Joe. Yeah he told me, my breathlessness stops me. Well, I'm probably not going off. You know what I mean? So that's what I need to know.
Now, Joe, I'll ask him chest pain. Let's see what a dancer is asking clearly and clear as to just spin and ask him what stops him. Ask him, Mr Smith. Mr smith, do you do you experience any chest pain? Yes yes, I do. OK does the chest pain that stops you or your hip pain that stops you, stops you from what you're walking?
Yeah so make it very clear what I want to write down when you walk, what stops you? Yeah it's the hip pain. Yeah so everyone, what we need to know is chest pain and breathlessness are two factors. Next, we want to know which drugs you're on, which are high risk for my consent. So, Joe, I'll ask him very clearly, do you take any steroids?
Most patients say Yes or no. They know that you take any drugs for it, for rheumatoid arthritis. In other words, you can't ask the patient, you take disease modifying drugs. You will know what you're talking about, but you are going to ask, do you take drugs for rheumatoid arthritis? And then you say, have you had any blood clots in the past and you take any blood thinners?
Right? and finish with a more or less. That covers my concerns. And of course, if he has thyroid, then you can ask him, do you have other medical conditions? And if you say if you had surgery in the past, are they are there any areas in your body which are raw areas or still leaky? Yeah, because you're going to appropriate?
He has also anything. So that's your last question. And you end with. What does your job. And if he says, I'm a plumber, say, are you still working or do you supervise? Yes and you smoke. Yes or no? And are you OK on ethanol?
That's how I finish. And if you ask these targeted questions in five minutes, you'll be impressing the examiner. You've taken complete control and that's what we want. If a patient is difficult, then please understand all of us realize in real life, in a difficult clinic it will be a difficult patient, right? But as long as we see or try and control and you know what questions you are asking, that straight away gives you a seven or eight.
But it's only comes if you practice these not going to cause us to listen to people just saying how they do it. Yeah, happy with that joke. Yes, Sean and David. And what will you add to that? I think I was just going to say with the history, there are so many questions to ask within limited time. You have to finish asking all these questions somehow within three, 3 and 1/2 minutes, probably four minutes, not more than this accounting for any surprises.
So if there are corners you can come to score hit two birds with one stone just should try build your technique and practice practice every day, for example, for the walking to hit these two birds. What I say the is, how far can you walk? Can you walk? In minutes, obviously. And what stops you?
Very good. One question, that's it. All done. So I know if they feel short of breath. I know it's not that hip. That's the problem. Yeah, good. Good for us. Thank you for that.
Questions and then you take peel-back two boxes straight away in one question. But some candidates tend to ask two or three questions about the same thing. Just one question covers one or two areas is the approach I would advise? Yeah OK. Yeah, the other thing is that for everyone, I mean, you know, go to most places, many people don't take so much effort to try to tell you about taking a history because all of your field and everybody says, oh, don't worry, let's go into something else because I know how to do it.
So but we need to get high marks. So please and all the effort of us and you all will be not there unless you really write down yourself what we've said and practice it for the next two or three days with whoever you want. But otherwise, we don't do it straightaway in the next 48 hours. It's out of your mind and you go back to your old questions. That's what I found would happen.
All right. So take advantage of that and probably wrap up this history section. I think just once before we go. So in terms of if you're coming towards the end of your history, you a quick summary of the problems to the patient. Axilo, so you can quite say you're also your Mr smith, this is your problem.
You got hit people last year, wake you up at NIPE. It's not to do what you want to do. Your plumber, is there anything I've missed? Yeah, David. Very nice, simple way. This one, and I remember someone giving me advice for this very simple way of making sure you don't miss anything. And if you summarize the examiner, that's it.
You summarized the patient. They can intercede. OK and all the time, the examiner might say, well, actually, that's enough that where you have summarized what is the patient, carry on the examination. David, thank you. I remember Sean saying it when I did the knee as well. So yes, David, I think that's very good to do, and it summarizes it once again.
What you're saying is that you're taking control of the situation and making sure you're not missing something with the patient. That's the focus, you know, rather than summarizing for the examiner. Yeah, yeah, that's a good point. Yeah so bring the patient to your side. Yeah, exactly. Exactly so, Mr Maddox, are you happy with the history as any other further comments you want to add?
No, not at all. I think it was good. We took this time on it because people don't, and I think it's five minutes offer one third of your marks, which I hope it's helped and we have enough. As you know, we never rushed these sessions, whereas this one, David, you know, we take time on your other important people the candidates need to get.
That's why we're getting all ask the question. So if we have to do another session on hip examination, so be it. You know, it can't be done in one. Yeah, just to say it carries a lot of weight history on an intermediate case. I think it weighs 2 vyver question to follow why the question is the same. So it's very easy.
If you score 7 in a history, it weighs a lot in the exam. It could pull you a lot up and you don't want to be scoring six or even worse, failing in history, which happens to be surprising. So you need to be scoring very high on and to compensate for other and easy. But as Mr Maddox said, we tend to think take it for granted. But if you talk to people who fail the exam, they tell you they failed in the history and in the easy cases where they took it for granted.
There are a lot to cover. We spent the whole hour trying to cover the history, so somehow you have to go back into this and build up a system for yourself where you can cover all these within four minutes. Just to reiterate, the history is not just as important as to others as far as I said, is absolutely correct, but it's also the foundation for your examination and your management discussion.
If you miss something like the patient is on warfarin, or if you miss that the patient's actual pain is not in the groin, but on the person, your examination is thrown away and your management is thrown away because you've missed the points that Miss a particular surgery that this patient has had somewhere around there, you might not look for a particular scar when at the time comes. These are all hints for later on.
The so I it's not just a matter of two vital questions that five minutes for us is absolutely correct, but it is your foundation for everything else. Yeah, cannot be taken short, full time. It's worth taking the time to practice. And another point we went over a patient with arthritic hip pain. Make sure you prepare your history taking for a younger patient with hip pain and possibly younger patient with leg length discrepancy or an older patient with leg discrepancy.
These are usually quite common, as well as all the other stuff around the hip and knee, but these are the big topics around the hip. Yeah, one more thing for us, you know, because one triggered my mind to something a young hip history will be different, but even an older person. Remember when we did our knee examination, when we finished knee pain, we went on to other symptoms and knees and in knees.
We asked for swelling. Now, obviously, I don't think we need to ask for swelling in the hip. Yes so let's not ask that as a general question. But getting up from a sitting position does your hip sometimes catch a look? That's quite common in arthritic, similar to the stiffness or getting up. let's ask that somewhere all of your please write it down that we have to ask that after we finish the pain.
Yeah and the next question have you noticed on the left side, Mr smith, have you become shorter on the left side? Let's all be clear, we're going to ask directly have you become shorter? Yeah, which is there as part of an arthritic thing. So do the three questions you ask there. And yeah, that's it from the history. And what do you think for us?
We should wrap up and make sure now we know that's working well. We know that we can have Mr Smith seen very well, you know, so we know we can next time get someone to come and do introduce themselves for the exam. So how are you going to tell them, remove their clothes, see the shoes, do get delegates or for any? One who is going to join next time we cover, if we're talking about other senior colleagues, we can do how to introduce yourself to say, remove your clothes, what which words, we are going to use, what are we going to say for examining footwear, how we see front backside inspection, how will do big test and get that'll cover a reasonable amount.
And then we go into the palpation and special tests. So maybe do sessions and recover a really good hip. Thorough examination with all of your involved. What do you think for us and John david? I think that's that, that's a very good plan that we be enough time I will go through it step by. think that's the right approach. Also by having a candidate to first take part and then we, you know, explain how to do it and give commentary and feedback, I think that sticks into the mind better than it would be two way interaction rather than just one direction.
So I think, Yeah. All right. Education, that actually very, very beneficial to all of us to watch all of this today. Thank you. OK there's a question, though, about paying increasing of the specific movement. Who is it from muhammad? So I think we've covered we've covered all that in terms of we're talking about the routines of the day that at risk getting up, get up walking up the stairs and up the stairs, go walking to the shops.
They've got a lot of movements in there. Certainly, I suppose, with some of the younger patients who worried about the snap ahead. You might get some specific movements then, but that's finished. So you've got to be quite careful. You don't go down a blind alley with that one. Yes, very good. I completely.
It's not helpful just to give. That once I just think of the prom questions that you get in Oxford here, which is basically what sort of going for those simple steps. That's what I have said already. OK, thank you, David. Thank you. Thank you, Mr Murdoch zavala, for this excellent session.
We all enjoyed it. And I hope that to everyone. It was definitely. I find it very useful myself. So Thanks to everyone who took part, just to remind you will try to run this session every Wednesday. So we will carry on, as I said, with the rest of the examination. At a later date, we'll let you all know, but you are happy, we will indecision.
And goodnight, everyone. Thank you. Excellent interaction. Thank you. Thank you so much. Thank you. Thank you. Bye bye. Bye bye.
Segment:0 .
Good evening, everyone, Thanks for joining and sorry about the delays this Francis teaching session from the farc, a splinter group. The presenter today is Mr. mavela. I'm sure you all know him. He's a consultant, surgeon and his senior mentor from with this group from the outset.
He's also a director of a very famous FARC course, which I've just shared here on the screen. I'm sure you guys would want to probably look at this. It is very well attended. And he has been running it for many years, very successfully. And he also has run previous sessions here on the examination, which have been received very well, and therefore we had the 100 for more clinical examination sessions.
And we have with us today also some of the other members of one who will act as the co examiner today. And we have also David, he's one of the senior mentors supporting decision myself. And for us, I'll be moderating, admitting you guys and shorting out participants and candidates. So I just want to say, obviously running an interactive clinical examination, teaching online as a webinar is very challenging task that you have prepared and spent hours preparing for without your active participation.
But I encourage all of you to step in and take part. That is candidates who took this very useful and assisted them to pass their exams and decided to run another one. So if anyone wants to take part, please either write express that in the chat box or raise the hand symbol next to your name and I will choose you to come forward. But if no one comes forward, I will have.
I'm afraid to pick people because it's essential to the successful running of this session to have active participation. And just that, we will respect, obviously, your privacy and participants participation. The performance of participants will not be recorded, and if recorded, it will not be published. It will be edited out.
And so there's just a final reminder, if anyone wants to CPD certificate for attending you entitled to one nice gift from the Royal College. So please contact me directly to get one. And without further ado, I'll leave you with Mr Malik's mavela to start the session. OK, thank you very much for us, and Thanks to John and David for being there.
Like I said, you may have attended a knee examination. I'm not sure if us was it about six months ago, maybe around that mark. Yeah, about eight months ago. Yeah, eight months ago. And we did two sessions. I think it takes. So what we are trying to do today is hip. A lot of the things may be repeated again, but it doesn't matter.
As you know, lower limb is vital for your intermediate case and as much practice as you want or you can get is good enough. So the way we do it and we'll start off in sorry for a delay, but it was very important that we do. This is we take our time. There's going to be no rushing of it. At the same time, it'll be completely interactive. I want every one of you all to imagine, and it doesn't matter what your performance because we just want to know how you present and how you talk.
Shawn will be my co examiner. Imagine that it's your let's start with being an intermediate case, and as you know, in an intermediate case, will be 5 minutes over history, five minutes of examination and 5 minutes of discussion, all in front of the examiner. So when we start the session, let me put a scenario to you that I got two of my registrars who have kindly taken their time out to do this. One of them will try to angle the camera at the best angle.
But please bear with us. Like I said towards the end, you are you. You finish in five now. I think we have to critique you. So I must say, and I think Shawn and David will agree that you are where you're talking, your clarity of your speech, your relation as to what you're saying is excellent. I agree with everyone, Shawn and David.
Good report. Yeah, thank you. So good rapport with the patient. So that's fine. Don't change that. Let's just now concentrate for everyone in the group on how to take a correct history, because please imagine and understand that the five minutes is critical for your marking.
You can't say that I'll do a good examination and 5 minutes of history. Now, in any history, this could be lower limb. It could be upper limb. Please understand. A we want to get to a diagnosis of what it could be. Abdullah Yes. And second, we need to know how bad it is for the patient. These are the only two things we want from our history.
So I just put up. So hence. Initially, for everyone, I wanted to introduce yourself like Abdullah did, so everyone's going to say that, say I would suggest, give you a surname as Mr. or doctor, whatever your surname is. But I'll leave it to you if you want to feel more comfortable. The first name, but you don't have to. My suggestion as being and seeing hundreds of people coming through is usual.
It's more professional to use your surname. Just say this, Mr smith, is it all right if I take a history and examine you? So in other words, you're taking implied consent. So you're saying that I want to do this? Yeah don't go on giving a long thing that I'm one of the candidates. I'm going to do this. I'm going to do that.
Just say, is it all right if I take it history and examine you a bit like you did? So very good. Next start. Very often you'll get a letter saying that this patient got left hip pain, Abdullah. So if you do get that, I would say, take that as a good sign and say, I understand you're sitting here because you have problems with your left hip, you know, so it means that you're constantly taking control of the situation that you realize the GP letter or what the examiners have told you.
So once you do that, try to focus what you ask was good that you say it. Tell me about your left hip. I think we have to start with that, and let's hope that the patient says that. Yes, I got pain in my left hip and the patient says it's 30 years now. Abdullah, he says. 30 years.
Do you think anyone has waited 30 years to see any of us? None of us are so important. You take 30 years to see someone, right? Abdullah is that correct? Yeah so therefore, try to say yes, I will come to your 30 year history, but please tell me what has made it worse. Now Is it worse over what to try to get to the present history? Yeah so everyone.
Try not to let a patient give you 30 years of history, otherwise you finish the exam the next day. Yeah, you have to try to do it and say, yes, I'll come to it, but tell me about your present history. Now the present history Abdullah is one year, so I ask him, yes, sir. Has it been worth over one year and then ask him, now I want you to ask him. Mr smith, when it started one year ago, did it start by itself or did it start with any history of injury?
Let me see how you ask him that. Go ahead. So how did this started in the last year? Mr smith, don't ask him that he doesn't know what to expect. You have to be clear, Abdullah, you know, he'll say, I started by I, you know, I had a fight to my wife, but that's not the answer of why. Or, you know, I had a fight with my neighbor. I was really upset.
You know, you don't want that answer because they didn't give you that answer. You have to know whether it started with very clear. Did it start with an injury, Mr. smith, or did it start by itself lost? Then so did it start it on its own? Or there was an injury that caused it myself? Oh, it started on its own. Yeah, so that's why I'm so now.
You're very clear. The onset was insidious. All right, Abdullah, now we move on. In the next year, you need to know whether it's become worse. It's become better. So ask him. I wanted to ask him. Mr smith, over the one year, has your pain become worse? Has it become better or are there some days worse, some days better?
OK, that's the answer you need. Ask him that. So Mr. Smith did start. Did the pain is the same or is it worse or improved? It's been worse for years now and since last year. It's getting worse. So you can't you get that answer now that is becoming worse, right? So that's your second thing.
And so you got the onset, you've got the duration of one year, you've got the progress, which is one year of becoming worse. Once you clarify that, Abdullah, I would like you to do ask you didn't. What you didn't do is you need to know very clearly any part of the body. And this is for everyone. Please don't accept the patient's word for shoulder, hip, neck.
They don't know whether or not they know where the hip is. What question do you want to know that it's a hip which all of us in the room are orthopedic consultants like yourself and myself mean? So when patients says hip pain, which part are you wanting to know where the pain is? Which part of the body? So where is the sight of the pain? So in a hip way, the sight which you are concerned about the groin pain, correct?
Fantastic so let's not use the word hip to him. Yes do you have any pain in your left groin and classical of that pain anywhere in the body now? You have to ask for referred pain. All right. So you say yes, you have pain in the groin? And does it come down to your front of the thigh, to your knee? Is that classical of hip pain?
Is that correct? Yes yeah, Yeah. So you ask him that say he says that? Yes, I got pain in my groin coming on it, and you are very clear you're dealing with the hip pain, which we know as orthopedic surgeons. Yeah if you commonly ask if you go to a shopping center anywhere in the world and you ask people where the hip is, where do they point to most of the time of the outside?
Fantastic, they point to a traject area. They point to their flank, they point everywhere else, which we know is not the hip. That's why I'm so particular. And the same thing with the shoulder you don't take. They would ask what you want. Yeah, that's what you do from now onwards onwards. Next, we go on to we used to rule out, I want you to be a safe surgeon.
What have you do? A hip for one of my patients as my colleagues and the patient's problem is, are back. Do you agree? It's a common scenario? Yes so have you demonstrated to schwann, who is my senior examiner that you've been safe and you've asked for the back? You agree you've not done that, you know, ask him, Abdullah, how are you going to root at this moment?
Once you've clarified the growing pain, you're going to rule out for my senior examiners that you're convincing him that you ruled out a backache. So ask him how I'm going to ask him all the back. And then for us after this question, do you mind switching to someone else and then someone else can have a Yeah. Mr smith, do you have any problems in your back or in your buttocks?
No, it's mainly the greens and any pain in the back of your thigh radiating down to the toes. No, Abdullah, fantastic. So this is where now you're very clearly asking correct questions. If he says back at buttock is one and the second question, does that pain go down the back of your thigh to below your knee with pins and needles? So this is classic of your symptoms.
I want you from today to write down classic symptoms of all parts of the body, which is going to ask as a direct question to patients. All right. So shoulder pain? Yes. Does it come down that aspect of the thigh? Sean and David will use some other suggestions. You know what I mean?
Try to prepare those in your mind and what's coming out of your mouth are not my mouth, not your mouth. All right. Yes thank you. Very good. Thank you. Very happy. Yeah well, I'm sorry.
Could I just the very opening line about what brought you here today? It's the classical thing we all do. I'm just as guilty as anyone else. But in the exam, remember, these people are volunteering their time. They're patients, they're volunteering their time, they're coming to help us. And often they're bored.
And they might say something like, yeah, an ambulance brought me or a car brought me, and that puts you on the back foot straight away. And they're there. They're there to help you, but they'll make some throwaway comments which will make your life difficult. Take control of the situation. The GP letter is there. It says the patient is coming with hip pain.
Say the opening line should always be something along the lines of hi, my name is Shawn Henry. Thank you for coming today. I'm one of the candidates. Your GP doctor says you're here for hip pain. Can you tell me more about your hip pain? You can start off like that, or you can be very direct about specifically the pain that they're feeling, but don't do opening lines like what brought you here?
I know it's a classical thing we always say to try to avoid that. Yep John, thank you very much. I mean, it's one thing exactly what I'm marrying to please all this new fangled way of being open and being things is not going to help you because the patient will say something like one thing which is not going to help you at all. And you don't want that.
So please, I completely agree. Perfect thank you. I didn't say that yet. I think she's on the right. Let's thank the patient for being here. As well as saying yes, I understand hip pain and stick to it. It's much better to stick to specifics. Yeah all right.
Who's next? Next, sheriff? Yeah, come on, Sheriff. You come in. This is your intermediate case, and here are your examiners. Sheriff Yeah. Can you hear me now? Yes Yeah.
OK, great. Thank you for getting on. Sherry flo, let's carry on from where we are. You've done your duration progress. Now you want to know that. What's your next question? You know where it is. You've classified it as no back pain. What's your next question going to be?
I'm very happy the way out in the question. So don't change that, however. Sheriff, what do you want from the patient now? Now that we've gone to this stage, you want to clarify how bad it is, right? The first was trying to get to a diagnosis more or less. We know it's like, Sean said, we are homing in on that. It's hip and groin. You need to know how bad things are for his pain, right?
Is that right? Yes, you need a few questions to clarify that. So one is, rather than lying on that side in your mind, if someone lies on that side, what is the clinical diagnosis most of the time, if he has an issue? Intra operatively bas status fantastic. But we hope that the patient doesn't have traject bas status because, you know, that's one of the most difficult and difficult and most unpleasant or unsatisfying things to treat.
And would that have groin pain? Unlikely, right? So the question you want to ask is Knight pain at night? The don't ask about sleeping on that side, I would say, ask him, Mr smith, does the pain wake you up at night? He'd say Yes or no? OK, that's one. Next, ask him, Mr Smith.
When you're watching TV, you get paid. What is that called? That's called rest respin. It's not called sitting. It's called respin. In other words, it's bad. Number three, Mr smith, when you get up from a sitting position, does it give you pain if you agree? Many people say, I can't get up.
Is that correct? In real life, Yeah. Yeah so that a thing they're climbing. You agree. Stair climbing is important that he finds difficulty climbing stairs due to being in the left hip Sheriff. Yes Yeah. And the fifth will be walking distance now, he said.
Shops now, unless you live with them, which are unlikely, you're going to live with Mr Smith. You don't know where shops are. So he said, shop and you let that question pass. So Sheriff, take control. Me and my examiner also don't know where he lived. So you say yes, I understand you can go to the shops in that. Thank you very much, Mr. But is that in how long now for everyone?
Most people and most patients cannot give a correct idea in meters, so just stick to time, say Mr Smith. Is it such that in how many minutes you have to stop because of pain in your left? To ask him that and he will answer you, gives you ask him exactly what you want to know in minutes. So when you walk on a flat surface, how long do you walk 10 minutes before you have to stop? Because of me clarity in the left hip?
Because patients? Yes, the doctor. But my Antoine is my senior example. Pick up that, you know, this patient has a very, very bad problem with his right ankle. And that's what's stopping him. You know what I mean? So be clear the left hip? Yes ask him again.
So how long? How long can you walk before you have to stop because of the pain in your hip? About 10 minutes, not more than 10 minutes. That's right, so, you know, you get an answer now. 10 minutes is a good answer that yes, I will offer him a hip if everything fits, you know what I mean. But if he says I can walk 45 minutes, then unlikely, you get a good answer.
So the way to remember this for everyone is remember an old man sitting and watching tv? That's a recipe. All right. Imagine the old man gets up to go to sleep, so he picked up this whole pain from getting up. Imagine he's walking through the stairs in his house. What's that called? That's your walking distance that goes up the stairs.
That's stair climbing. And he sleeps at NIPE to the 5 points of severity of pain have been covered. Right? so don't. This is the best way of remembering it, and I want it to go very quickly, but very precisely to get the information. You can remember it. You can remember it by man sitting and watching TV, and he gets pain.
So remember, you would ask him and that's resting. Then you're going to imagine that you're going to sleep. So he gets up to start walking. And that's pain when getting up or sitting positions and say, messersmith, you get pain when you get up from sitting position. The third is he walks to his stairs and that triggers your mind to talk about the walking on a flat.
So, Mr smith, when you walk, how many minutes can you walk before your left? Hip pain stops you? Then he goes up the stairs. So yes, when you climb stairs, do you get pain? And when he sleeps at night? Yes do you get pain at night? That's the way I remember it. So I never forget 5 points for lower extremity and use this for back, hips, knee, ankle, whatever you want.
Yeah, happy with that. So I thank you. Very good tip. I use slightly different. I say, can you get up off your chair? Do you have pain when you're sitting down and you get up, you stiff and difficult to walk? Do you have difficulty going up the stairs to put on your socks and change your clothes to come back down, to go to the shops?
Any difficulty doing that? That, to me, reminds me of pretty much eight of, sorry, six of the questions that you need to ask, which are not to do with the intensity of pain in the ass. Thank you. That's a good way of adding on two more points. I'll remember it for next time that we'll combined it. But what I want to tell all the candidates is that we are both experience, but we still need triggers in our mind to get it right, right?
So it means please remember that taking this exam is not something that you can go to. All the courses, see patients, it's what comes out of your mouth. So please practice these phrases. Yeah, that's that. So now you finish that sharif, and we'll finish one more question with you once you finish that. What do you want to know?
You've got your pain. You've got to intensity. You've got your socks and shoes, getting it out of a car, which are classical of hip pain. Then what? What do you want to ask then? I want to ask about his job and any hobbies or activities which are typekit before that, before you go to back. Hobbies my best guess for you is to try and do.
Another heading is other joints and fast hip history. So let's stick to past hip history. Yes and then other joints. So in past hip history, remember he told us he's the same patient. Remember, he told us that he had operated in childhood. Now, say that, Mr smith, please tell me when you were born, did you have any problems with hips and knees? Ask him that.
OK, Mr smith, when you were born, did you have any pain in your head for needs? Did you have any problem for me? Yeah, I had a problem. The hip? Yeah, I had a problem in the hip. My parents told me that I was limping for most of the time. OK, so that's one. Then next, say then say, when you were younger, did you have any operations of on your hip and you say yes?
When I was seven years old, I had an operation done. So you can ask him that and you can say, yes, I had the metalwork removed. Let's that. Yes, you got that answer. So every patient, you're going to ask any problem with your hips and knees when you were born. The second thing you ask him is any operation to your hips and knees in the past.
Third, you can ask any fractures of your pelvis, femur or tibia. I want you to ask every patient that to ask him that exhibit. Have you ever had? So have you had any fractures in your leg? No leg is something which his leg maybe is toe. You want to know pelvis. Most people know pelvis. Most people know femur. And most people will know tibia.
And you can still see it. And within five minutes. So I'm not, I'm not making you take longer, but you need this answer rather than later. Forget him again. Did you have any great thing, your pelvis or your femur or tibia or your tailbone, rather than femur and thigh bone and leg bone? No, not that I remember.
Yeah so that's a good point at all, Sheriff. Right, thigh bone, leg. So that's what you asked for, fast hip history. And then you can ask, do you use any painkillers? And do you use any crutches or sticks? So in other words, I don't like asking what you're taught in many courses about. Please tell me, aggravating and relieving factors. The reason I don't ask this is aggravating factors will not help me because the aggravating factors may be something which is like I can get into a low car, but I'm not going to do a hit because you can't get the local, you know what I mean?
I need the answers and relieving factors. What you're indirectly asking is what treatment have you had? So the best way of putting it is in the past hip history and for everyone, try to keep this for past knee history, for spine history, all the same, you know, the headings are all the same. Complained how bad it is. So I'm just recapping again its present complaint. How did it went?
How did it start? When did it start? What is the duration and whether it's worse or better? Next, go on to where is the site of the pain and ruling out referred pain, right? Third is intensity of pain with all these questions, which with a combination of mind and tshwane's about how bad it is. Fourth is past hippie streak, which we've done, and now we go on to other joints.
It tells me you told me that your other joints replace you say yes, I had my right hip left knee. Is that a good head injury? Happy with that headings. Yes and now you can Sean and David, if you to add anything. And then we can move on to another candidate for us. Can I just there's one known question the candidate asked about the difference between pain and chest pain and what does it mean?
I think my take on this is that for, you know, for the exam, you want to take the lead and the control of the situation. So the question I would put to the patient here is does the pain wake you up from sleep? Fantastic very good. I agree. And all of this and what does it mean? What does it not mean or do you want to do is how is the pain restricting the patients daily life?
We're not inquiring about possibility of infection or tumor here, because that would take another line. You just looking at its effect on daily life. But just a simple question does the pain wake you up at night? Yes or no? Yeah, that's just my take on this. Very, very, very good point. And let's stick to that without a doubt for everyone.
So the point about so the question is being asked, how does this differentiate between pathology and infection? Correct but at this stage, we're not trying. These questions are not there to confirm our diagnosis. These questions are there to score this patient on what we call patient related outcome measure. In this one, it's the Oxford Hip Score.
If a copy of this on the telegram just now, so you guys can look at it later. So these are differentiating questions in terms of scoring marks which have been validated to study the severity of this patient's pain. We're not at differential diagnosis. And as for us said, my pain is a specific thing that wakes the patient up at NIPE and at rest.
Pain is a pain that when the patient is sitting down resting, this hip stiffens and he gets pain. These are not to do with differential diagnosis of pathology such as Kessler. Excellent yeah, that's Yeah. So and all we are trying to get at is the severity for four lesions that we need to know of. But more importantly, just let it come from your mouth as to what your phrase is going to be, which is correct.
So now we move on because we someone else, we're just to end this. Thank you, Sharif. Well done. We move now to Joey. Hi, Joey. Hello Hi. How are you? I'm fine.
Thank you. Do how are you? Well, you are the next candidate. We have two nice examiners here. Come in. This is your intermediate case. Yep so you're carrying on with the same thing. Imagine you're carrying on now. You've asked this, you're going to what are you going to ask next?
So you've done your security, you've done your past other joints, you've done your past hippie streak. Mm-hmm So I will proceed with. OK finish that because you're so. In other words, let's agree with everyone that once we finish the hip or the spine or the knee and peace, take this as a generic good history taking which one and for us and David to give you tips on.
So Joe, in your mind, once you finish that part, we all agree in an intermediate case, at least we have to take a history of what we call medical history or social history. Is that right, joe? Is that what you wanted to know? Yeah so I always feel a mind triggers up to something. So once you finish that you need a trigger to say you're finished with your hip and going onto something else.
So I ask at this stage, please everyone ask allergy. All right. Allergy is quite an important, I would say, when Ashwin and David and for us, but I think it's a very important question. So the allergy I need to know is, are you allergic to any drugs and any metals now? It's a controversial topic to know whether, but I still ask it OK, because we're using skin staples, you need to know that.
So let's ask everyone from today onwards, Mr smith, are you allergic to any drugs or method? And that's breaking the ice moment. It triggers your mind that you're finished your part and going on to a medical condition. Joe? yeah, yeah, OK. Now when you go medical condition. Please, you can ask what medical conditions you suffer from, but once again, I don't know what you are, and for us, in David's view, is but 1 May agree with me that if you ask that you'll get a 10 minute rant on something of his medical conditions, which you are not really helping you as a hip surgeon, what you need to know is with your consent change and you will give him a high risk factor for my hip replacement I'm doing.
That's right, Joe. And secondly is whether he merits a hip replacement or is other medical conditions more important, which is stopping his mobility? The anesthetic assessment is not for me or you to make. We are not anesthetic consultants or police, right? So all I ask, therefore, is let's ask the questions that Mr Smith. Do you suffer from any diabetes?
You're getting diabetes? I need to know because my risk factor will say, sorry, you are at a high risk for infection. You agree with that, Joe. Would you not tell him that? Yes, you ask diabetes next. You have any take medication for blood pressure. Why? because uncontrolled or fragile off label blood pressure is contraindicated for elective surgery.
You agree with that, joe? Yes Yeah. So your last blood pressure in tablets and is it under control? Number three, you can ask him. Have you had any recent heart attack or stroke? Do you agree you do not do your hip or knee for one year after a recent heart attack or stroke? Yes we're going to ask him that then when you ask the two questions for breathing.
It's a slight. Lined flat is not the issue. You want to know whether you do a hit or not do a hip. So the question I ask him is as follows Mr smith, you have listened to what I'm saying. So Mr smith, you have problems of breathing, but you get you get breathless. If you get breathless. Yes yes, Yes.
So what stops you when you walk? Does your left hip pain stop you or your breathlessness stops you? And if it's still active now, you're clear that you offer him a left hip to Joe. Yeah he told me, my breathlessness stops me. Well, I'm probably not going off. You know what I mean? So that's what I need to know.
Now, Joe, I'll ask him chest pain. Let's see what a dancer is asking clearly and clear as to just spin and ask him what stops him. Ask him, Mr Smith. Mr smith, do you do you experience any chest pain? Yes yes, I do. OK does the chest pain that stops you or your hip pain that stops you, stops you from what you're walking?
Yeah so make it very clear what I want to write down when you walk, what stops you? Yeah it's the hip pain. Yeah so everyone, what we need to know is chest pain and breathlessness are two factors. Next, we want to know which drugs you're on, which are high risk for my consent. So, Joe, I'll ask him very clearly, do you take any steroids?
Most patients say Yes or no. They know that you take any drugs for it, for rheumatoid arthritis. In other words, you can't ask the patient, you take disease modifying drugs. You will know what you're talking about, but you are going to ask, do you take drugs for rheumatoid arthritis? And then you say, have you had any blood clots in the past and you take any blood thinners?
Right? and finish with a more or less. That covers my concerns. And of course, if he has thyroid, then you can ask him, do you have other medical conditions? And if you say if you had surgery in the past, are they are there any areas in your body which are raw areas or still leaky? Yeah, because you're going to appropriate?
He has also anything. So that's your last question. And you end with. What does your job. And if he says, I'm a plumber, say, are you still working or do you supervise? Yes and you smoke. Yes or no? And are you OK on ethanol?
That's how I finish. And if you ask these targeted questions in five minutes, you'll be impressing the examiner. You've taken complete control and that's what we want. If a patient is difficult, then please understand all of us realize in real life, in a difficult clinic it will be a difficult patient, right? But as long as we see or try and control and you know what questions you are asking, that straight away gives you a seven or eight.
But it's only comes if you practice these not going to cause us to listen to people just saying how they do it. Yeah, happy with that joke. Yes, Sean and David. And what will you add to that? I think I was just going to say with the history, there are so many questions to ask within limited time. You have to finish asking all these questions somehow within three, 3 and 1/2 minutes, probably four minutes, not more than this accounting for any surprises.
So if there are corners you can come to score hit two birds with one stone just should try build your technique and practice practice every day, for example, for the walking to hit these two birds. What I say the is, how far can you walk? Can you walk? In minutes, obviously. And what stops you?
Very good. One question, that's it. All done. So I know if they feel short of breath. I know it's not that hip. That's the problem. Yeah, good. Good for us. Thank you for that.
Questions and then you take peel-back two boxes straight away in one question. But some candidates tend to ask two or three questions about the same thing. Just one question covers one or two areas is the approach I would advise? Yeah OK. Yeah, the other thing is that for everyone, I mean, you know, go to most places, many people don't take so much effort to try to tell you about taking a history because all of your field and everybody says, oh, don't worry, let's go into something else because I know how to do it.
So but we need to get high marks. So please and all the effort of us and you all will be not there unless you really write down yourself what we've said and practice it for the next two or three days with whoever you want. But otherwise, we don't do it straightaway in the next 48 hours. It's out of your mind and you go back to your old questions. That's what I found would happen.
All right. So take advantage of that and probably wrap up this history section. I think just once before we go. So in terms of if you're coming towards the end of your history, you a quick summary of the problems to the patient. Axilo, so you can quite say you're also your Mr smith, this is your problem.
You got hit people last year, wake you up at NIPE. It's not to do what you want to do. Your plumber, is there anything I've missed? Yeah, David. Very nice, simple way. This one, and I remember someone giving me advice for this very simple way of making sure you don't miss anything. And if you summarize the examiner, that's it.
You summarized the patient. They can intercede. OK and all the time, the examiner might say, well, actually, that's enough that where you have summarized what is the patient, carry on the examination. David, thank you. I remember Sean saying it when I did the knee as well. So yes, David, I think that's very good to do, and it summarizes it once again.
What you're saying is that you're taking control of the situation and making sure you're not missing something with the patient. That's the focus, you know, rather than summarizing for the examiner. Yeah, yeah, that's a good point. Yeah so bring the patient to your side. Yeah, exactly. Exactly so, Mr Maddox, are you happy with the history as any other further comments you want to add?
No, not at all. I think it was good. We took this time on it because people don't, and I think it's five minutes offer one third of your marks, which I hope it's helped and we have enough. As you know, we never rushed these sessions, whereas this one, David, you know, we take time on your other important people the candidates need to get.
That's why we're getting all ask the question. So if we have to do another session on hip examination, so be it. You know, it can't be done in one. Yeah, just to say it carries a lot of weight history on an intermediate case. I think it weighs 2 vyver question to follow why the question is the same. So it's very easy.
If you score 7 in a history, it weighs a lot in the exam. It could pull you a lot up and you don't want to be scoring six or even worse, failing in history, which happens to be surprising. So you need to be scoring very high on and to compensate for other and easy. But as Mr Maddox said, we tend to think take it for granted. But if you talk to people who fail the exam, they tell you they failed in the history and in the easy cases where they took it for granted.
There are a lot to cover. We spent the whole hour trying to cover the history, so somehow you have to go back into this and build up a system for yourself where you can cover all these within four minutes. Just to reiterate, the history is not just as important as to others as far as I said, is absolutely correct, but it's also the foundation for your examination and your management discussion.
If you miss something like the patient is on warfarin, or if you miss that the patient's actual pain is not in the groin, but on the person, your examination is thrown away and your management is thrown away because you've missed the points that Miss a particular surgery that this patient has had somewhere around there, you might not look for a particular scar when at the time comes. These are all hints for later on.
The so I it's not just a matter of two vital questions that five minutes for us is absolutely correct, but it is your foundation for everything else. Yeah, cannot be taken short, full time. It's worth taking the time to practice. And another point we went over a patient with arthritic hip pain. Make sure you prepare your history taking for a younger patient with hip pain and possibly younger patient with leg length discrepancy or an older patient with leg discrepancy.
These are usually quite common, as well as all the other stuff around the hip and knee, but these are the big topics around the hip. Yeah, one more thing for us, you know, because one triggered my mind to something a young hip history will be different, but even an older person. Remember when we did our knee examination, when we finished knee pain, we went on to other symptoms and knees and in knees.
We asked for swelling. Now, obviously, I don't think we need to ask for swelling in the hip. Yes so let's not ask that as a general question. But getting up from a sitting position does your hip sometimes catch a look? That's quite common in arthritic, similar to the stiffness or getting up. let's ask that somewhere all of your please write it down that we have to ask that after we finish the pain.
Yeah and the next question have you noticed on the left side, Mr smith, have you become shorter on the left side? Let's all be clear, we're going to ask directly have you become shorter? Yeah, which is there as part of an arthritic thing. So do the three questions you ask there. And yeah, that's it from the history. And what do you think for us?
We should wrap up and make sure now we know that's working well. We know that we can have Mr Smith seen very well, you know, so we know we can next time get someone to come and do introduce themselves for the exam. So how are you going to tell them, remove their clothes, see the shoes, do get delegates or for any? One who is going to join next time we cover, if we're talking about other senior colleagues, we can do how to introduce yourself to say, remove your clothes, what which words, we are going to use, what are we going to say for examining footwear, how we see front backside inspection, how will do big test and get that'll cover a reasonable amount.
And then we go into the palpation and special tests. So maybe do sessions and recover a really good hip. Thorough examination with all of your involved. What do you think for us and John david? I think that's that, that's a very good plan that we be enough time I will go through it step by. think that's the right approach. Also by having a candidate to first take part and then we, you know, explain how to do it and give commentary and feedback, I think that sticks into the mind better than it would be two way interaction rather than just one direction.
So I think, Yeah. All right. Education, that actually very, very beneficial to all of us to watch all of this today. Thank you. OK there's a question, though, about paying increasing of the specific movement. Who is it from muhammad? So I think we've covered we've covered all that in terms of we're talking about the routines of the day that at risk getting up, get up walking up the stairs and up the stairs, go walking to the shops.
They've got a lot of movements in there. Certainly, I suppose, with some of the younger patients who worried about the snap ahead. You might get some specific movements then, but that's finished. So you've got to be quite careful. You don't go down a blind alley with that one. Yes, very good. I completely.
It's not helpful just to give. That once I just think of the prom questions that you get in Oxford here, which is basically what sort of going for those simple steps. That's what I have said already. OK, thank you, David. Thank you. Thank you, Mr Murdoch zavala, for this excellent session.
We all enjoyed it. And I hope that to everyone. It was definitely. I find it very useful myself. So Thanks to everyone who took part, just to remind you will try to run this session every Wednesday. So we will carry on, as I said, with the rest of the examination. At a later date, we'll let you all know, but you are happy, we will indecision.
And goodnight, everyone. Thank you. Excellent interaction. Thank you. Thank you so much. Thank you. Thank you. Bye bye. Bye bye.
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