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The FRCS (Tr&Orth) Clinical Examination Experience
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The FRCS (Tr&Orth) Clinical Examination Experience
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Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
Not us. Thank you, everyone, for coming today. First of all, I would like to congratulate everyone who passed the recent exam. Either part one or part two annotation will help you focus a little bit on what might have been wrong or what you could have done to pass it this time.
So again, what is this talk about? It is my approach to the exam, and during this presentation you would find that some of my colleagues would mention slightly different approach in certain aspects. There are many ways of skinning a cat. No one correct way. You have to find your own way. But I'm just presenting my experience and you can take whatever you find useful from that.
What is this presentation, not I'm not going to tell you how to examine a joint or how to take a history. OK, you've been doing orthopedics for many years. All of us. And this is not the chance to do that. But what I'm going to tell you is how I approached the exam as a task and how I did to get this task done with the minimal effort possible.
Ok? and I will guide you. I'll tell you where you can get more information or more experience. In fact, tirath told us to choose the clinical part because this is the part that is neglected during all the sessions we do in this and many courses neglected, although the clinical part is half the exam Hall presentation.
And I think if you can take one thing, one sentence from the whole presentation is planning is everything. You have to plan and you have to plan early and you have to plan correctly, and you have to put timescale into that plan. You have to know how many months you have into that exam and what are you going to do in each month until the exam? And you can score more in the clinical that's compared to the virus.
And if you practice these clinically well and stick to your system, you would find what the positive findings are in the patient. You can present them and then that's how you are going to score. But your technique is going to be different. Not everybody is the same way. But make sure that you take all the boxes, you do all the relevant tests and you don't miss out on anything.
And if you see something positive, just say it did and go for the kill. Like, for example, if you see a cable for, say, it's a giveaway to sport and then move on and do other things, OK, fine. So we'll get to that. So but we agreed. Now the clinical and I agree with Abdullah is more important than survivor.
Most of us pass or fail on the clinical day. So the first day of the exam, and we don't give that enough attention as much as we give to the Viva. OK, so the next point I would like to make is, what is your target? OK, what are you aiming to achieve, what the examiners want to see in you? The most important thing is they want to see a colleague.
Ok? the farke's the fellowship is a club. They will not invite to the club, and anyone who doesn't look like the rest of the members of the club looks like them. Behaves like them. Talks like them. And that's what you want to achieve. Look at your consultants.
Imitate them. OK, this is what you want. The next thing and I tried to put them in order of importance, the next important bit is that you need to be safe. They want someone who is really safe in handling patients. They don't want someone who would bring their trust complaint after complaint. OK they want someone who is confident.
Whatever you say, say it confidently. Most likely, you will be right, ok? But if you sound hesitant, you make the decision in a hesitant way. They would think he's just looking. He's just, you know, hazarding a guess. Whenever you're stuck and you will be stuck in the exam, believe me, I've been there and I've been stuck several times just to be systematic and logical.
What I mean by that is have a system you fall back into. For example, if you are listing the causes of something, have a system, either you would say it could be congenital, it could be traumatic, it could be endocrine, it could be whatever. OK, that's one system. The other system is it could be acute and chronic as long as you have a system to fall back to. They will be happy as long as you make a logical decision and make sure that they listen to the decision process.
For example, in the exam, I had a patient with a funny diagnosis. She had a hand that she could not move with muscle wasting. So I said she has sensation. But inability to move so it cannot be completely neurological, so it's either only motor. Or something else muscular? Now I was unable to move the joint, so it's not muscular and I was saying that loud, so he said correct.
What could it be? It took me a bit and then I said it's after process. And he said, Yes. Correct Yeah. Excellent example. Yeah next, they want someone who can cope with variations, either variations in presentation or variations in management, so be prepared to have a slightly wider scope of thinking.
Don't go just this is a practice. I need to do a joint replacement. Make sure that you have a broader view of the condition and the patient and the most important thing and the thing that a lot of us will fail with is the familiarity with the UK system, especially people who hasn't been in this country for very long. OK they don't want someone who would practice American or European or Middle East or Indian medicine.
They want someone who would cope well with the UK system. OK and the last bit and I made sure that it is the last bit. They want someone who is knowledgeable, ok? Everyone says you've proven that you are knowledgeable by passing part one. They don't want your knowledge. They want to see that you can use that knowledge to help the patient. OK and that's what they want.
Any other points, Usman or GQ that you think that they would look for in the candidate? Yeah I think like, no, you should be very sleek and very systematic. So rightly said so you should. We should have your method of expressing a particular information across your. You might not have to list it all the 10 causes of particular of your particular condition, but you should be very systematic and organized the way that you are putting it and in clinical and you should be very, very sleek when you are looking examining the pieces.
OK, so the next how I did that. So the most important thing is to start early. And by early, I mean, months and months and months in advance and ideally a year in advance. OK, the way you do that is you put a plan. And you start by recruiting your own consultants. The best thing I had is I had a helpful consultant in my trust who took the time off to take us through difficult x-rays and let us talk about them in a systematic way.
And he spent about a year doing that almost once every two weeks, half an hour, every week. The importance is not that the amount of time we do in each session is we are doing it over a long period of time. Now you don't have to have that level of commitment by it from your consultant. All what you need is someone who would take the time and tell you, this is an interesting case.
I would like you to examine it in front of me. Or tell me about how we do approach this condition or during the operation while you are assisting him, take me through the approach of this. The important is you have to have someone who's passed the exam taking you frequently through that over a long period of time. This is the most important thing if you cannot have that, and many people cannot have that.
You should have some point number three. OK and that is for everyone as well. Former group Usman knows he was one of the group we chose. We started early. And we chose a reference on our reference was asked which? We chose that book to cover the whole syllabus. We decided that this is the book we are going to read. These are the chapters, we are going to read. This is the pattern we are going to use.
And that group doesn't have to be in one physical place because one of us was in Birmingham, the other in Scotland, the third in London, and the fourth was somewhere in Nottingham and I was in yoga. You can use Skype. And as long as you have a defined time every day or every other day, you find no and you start again, then did it again. And the most important thing is we implemented that in the clinic.
But they want to see in the exam is what you do in your clinic, and it'll show. Believe me, if it is the first time you're doing it in the exam, they know if it is only the fifth time they know it will look. You cannot hide that. You have to have done this in the clinic with patients. Tens of times for it to look slick. OK the other thing is, there is no time in the exam to think of the next step.
You have to have done this so that it becomes like a second nature to any exam is study the same way you are expected to be presented. So for a clinical examination, the best preparation is examine a colleague, examine a patient and see someone examining their OK because this is the fastest way of what they call it, a muscle memory. So it becomes like a muscle memory, you are doing it in the exam as natural as you would do it in the clinic.
Again, I will stop and cosmological. And I think this is very important that you make your system and you practice it when you are doing your clinics in the hospital. Like if you are practicing it on each other, it's easy. You have done those examinations and the other person who is mimicking the patient. And if what you're asking him to do, if you try that on a patient in the clinic, it's a completely different experience.
They are not familiar with the examination. And that's the time when you get your confidence, when you do it again and again in clinic. And that's basically what I did in my fracture clinics, in my elective clinics. I examined the hips, knees, elbows, shoulders, all these joints. I did it repeatedly on the patients and that kind of ingrained that reflex action that if you are asked to examine a hip or elbow or the knee, you start doing it, but do it in a formal session.
And in the end time as well. Yeah, so this exam is not an exam that you can go solo because I have prided myself a couple of times and I failed miserably and I've got a by God's grace, I got a good partner and we studied together. So when you study with your colleague, you will reach one particular level.
Then you discuss that particular topic with one of the specialists in that field, and your knowledge will go one notch higher about 4 to six months to the exam. What you can do is every clinic session that you are attending. Choose one or two cases, which it can be any case, but tell the patient that we are going, you are going to take an exam. I want to take a 5 4 minute history from you.
Then I will summarize your findings to you in about one minute, then stick on to the 5 minute examination and up and present your history and examination to your senior colleague or one of the specialists that is helpful to you and take the discussion from there. I think that I found it very helpful. I think that's very helpful, but I would advise colleagues that when you do that, don't have a look at the notes or x-rays.
You just go pick any patient randomly from people waiting and bring them to the room and start from 0. So you will know possibly this is an upper limit or lower limit clinic as an ankle and foot ankle. This information will come to you. You can't avoid it, but don't open the nose or look at the x-rays before examining the patient. So we started all the joints, then the elbow joint, then the wrist joint and the hand, then hip, then knee just normal joint on each other.
And we kept repeating that until it. A second. Then we moved to examine the joints as if it's an intermediate case as you do the whole. All the tests that takes a lot of time. You do that until it becomes a second nature. And the way we did it initially is on each other pretending to be patients, pretending that there are some findings, but then you move on to examine it on patients once you have a chance.
Ideally, you should be able to do that every week, as you said in the clinic. But then it is. We're doing it in front of each other so that there is someone who is stabbing you, correcting your mistake at once. We must address you to do the examination as if it is a short case. Ok?
and there is a difference between the two techniques. The first technique. You do it properly. You do all the tests. The second technique, you have to immediately choose which tests you have to omit. Which tests you have to do very quickly because all what you have is about two to three minutes. During that time, you have to have finished your examination, presented them and ready for them to ask you, what are you going to do with this patient?
This doesn't work for every joint or for every case. But if you practice it enough, it would be good for you if you will cover the majority of the exam. And as I said, you have to implement that in the clinic. We had the time as every case, every examination should not take more than five minutes. OK and we use video, so one of us will be examined, the other one will be examined and the third is holding a video.
We did not take a about practicing it and be doing yourself. We tried that as well, and I think it really helps. You can see yourself what you are doing and you are your best critic and you can iron out the problems that you are having by watching yourself and doing it. What is my body language like? How am I standing handling the patient where my hands are? It's all about refining that performance.
You are giving a performance on that day. So it's all about that, and the more refined you are, the better you will score. OK so the next is the exam itself. Now you have done all your preparation and you are in the exam, ok? The important thing and I cannot stress this more than, you know, I cannot stress this more.
The saying is those who fail to learn from history are doomed to repeat those who fail to take a proper history to repeat the exam. I think all you take, all your clinical examination hinges on taking a proper history and from getting some feedback of people who failed in the past the majority of the time. The problem is either the assumed that the diagnosis is something because they did not take a proper history and they went to the examination to prove that while it is completely different, I'll give you an example.
One of my colleagues failed the case because ask about infection and assume that it is a dysplasia, while the problem had a previous infection in the hip joint. So that destroys the whole case. OK, I'm sure he felt because of that. If you do not take a proper history, you might as well go home. OK, next, which is very, very important, this is another failure point.
Respect the patient. We don't handle them roughly. Don't talk town down to them. Thank them when they come and thank them when you leave. They have taken some of their time to come and help you be seen to be polite to them and appreciative of what they do. OK but at the same time, don't let that hinder you from getting what you want to get, which is a proper history and proper examination.
So deal with them as if you deal with them in the clinic. Very polite, very professional. But to the point there isn't enough time to talk about their dog or what they had for lunch or things like that. The next point can be controversial, and I'm saying it deliberately aim to get the differential diagnosis, not only one diagnosis.
OK the reason I say that is I've seen many of my colleagues. They're the first couple of sentences from this story. Make sure that, you know, they get a diagnosis and they stick by it and assume it is correct and they run with it. If you take the history you say, for example, this is likely to be arthritis. However, I may need to exclude infection. I may need to exclude pain coming from the spine.
And you go to the examination to exclude those two things. You will not be mistaken if you go back to the example I gave earlier, my colleague who assumed that it is simple arthritis and forgot about the infection. We have that made that mistake if he had a slap road in mind. So this is likely to be arthritis, but I have to exclude infection. OK, next, while you're taking the history, it's not only about what problem.
They make sure that you look into things that would alter you management, for example, does the patient have other medical problems that would stop you from having the operation? Does do they have? Did they have an operation before? What sort of treatment they had? Are they willing to have an operation or not? OK The most important thing, again, is listen carefully.
Believe me, they will drop you hints right, left and center. It is your duty to take them. Really? listen carefully. The patient will tell you, the examiner will tell you. And when you say something wrong and look at the patient a lot of the time, they sympathize with you and they want you to pass. And you can see from their reaction that you've missed something.
So be attentive, ok? Next is be systematic in your history, if you jump right, left and center, you will score badly and you will likely to miss points. Start with the I mean, we all know how to take a history present complaint. You know, talk about the present complaint. Are the complaints, other systems, you know, we know how to do that.
The next thing is, don't forget infection, prevent infection and previous infections and clotting again, whether they are on anticoagulation. And the risk factors for DVT. These can be used to because if the patient has already some infection somewhere and you offer them an operation that you may kill them, so be careful with that. Any practical points from the history taking in the exam, guys Chico and Usman.
Yeah, so now I don't know whether it was like that before, because why? What I have noticed now is that there is a lot of crossover of cases now. Previously, like we thought, like intermediate cases will be a hip case or a spy case or a shoulder case or any case. But for me personally, I have got like this, this exam. I got a pigment that we don't know where it is of the finger, which is a small, tiny swelling in on the camera aspect of the proximal phalanx.
And you have to take you have to ready to take a history, a five minute history and do a five minute examination on that particular patient. Another time I got a post-traumatic likely a snack or a slap, which if you are not ready to take a history or terrorist case, you will be found stuck in that particular situation, so you should be ready to take history in any case. So don't think that, like you know, the intermediate cases will be all the standard cases which we think about.
You should be ready to take history in any case. So there is no compartmentalization between the intermediate and the shortest. That's true. That's true. I think that's very, very important. I think that's the value of having you guys who are fresh because I think the previous understanding is that an intermediate case has to be hip.
Arthritis has to be knee arthritis, ankle spine. But as you explained, it could be anything could be condition a simple thing or simple hand, or even could come as an intermediate case. So thank you on the hand by our table, and we don't emphasize so much on history taking. You can gather a lot from your history and you can score a lot of points from your history if you are presented with the problem you face if you haven't seen it before.
Ask about the problem. When did it start? How was the patient? How did the patient become aware of it? What if he had any treatment for it, but tried so far all these things? Then the next thing you can ask is how did the patient, their occupation, the day to day life, the sleep, walking all of these things?
And then you move on and you ask about the past medical history. But if you get anything positive in the history, like if the patient tells you you've had any surgery, then try digging into it and ask them, when was this? Why was it done? Were there any complications like, for example, I had my intermediate case. There was a child who was 62 years old and he had a problem with his hip.
And I asked him in the first thing he said to me, I had a hip replacement 20 years ago, so that would ring a bell. This chap had a hip replacement at the age of two, must have had some problems with the. And that led on to the discussion here 30 of the. And so you need to find those things out and you need to go in with an open mind, but you need to have the system for your history. I think most of us, when we practice for the clinical, we skip the history taking.
We think it's the easy part is the most important bit. Exactly you'd be surprised how many people fail in the history, and it's shocking because you think a doctor at this stage, history making history is the easiest, but it has to be focused, specific history, taking with the limited time and focused helping you find the diagnosis and the management. And I just think when I was practicing, I could add to people advice here.
I practiced that. The last question I ask in the history at the end of the five minutes is to ask the patients, what are your expectations and what are you? What do you hope to achieve from this consultation? And I think if the patient is on your side, you'll be surprised what information you get from this. From this asking this question, if you've been good to the patient and the patient likes you, they can at this stage give you information you might have missed during the whole history taking.
So I think variation of that question is summarizing to the patient and then say, what have I left out anything? Is there anything you'd like to add? And then you expect this from today's consultation if they say, no, no, no, I don't want an operation I want, then you've got your pathway set up already by the patient and the patient will tell you you've missed something in. Yeah, I forgot to tell you, I'm on anticoagulation, but does that make sense?
Or you might have forgotten that, she said. They're on anticoagulation. It could be something very subtle that is very important. And I apologize. I have you covered it very well. There is a couple of other things in the history, which I think is very good to put in things like are you a smoker? Are you on blood thinners or you have any heart problem, breathing problem?
Or are you diabetic or using steroids? Those are Yes and no questions, because if you miss those, your management plan goes down the drain. OK, so I don't. Those I consider quite important. Just as the end part, just before you start to summarize to the patient what you found. I know it's hard to include all of this in your five minutes and to reinforce what Abdullah jaka and Mohammad one said they are.
The history sets you up for the rest, we talk about independent marketing opportunities. What if you don't do the history correctly, you're not going to get the marketing you need in the examination because the and you're never going to get to the management because if your history, the patient or an infection, there's no you're going to miss the scar that's potentially looking with a sinus.
This might miss the patient complained of stiff elbow decreased range of motion. The injury led to instability of the elbow, but he becomes so arthritic that it became a stiff elbow. So when I did my examination, I didn't examine for instability because I specifically asked them the history does your knee pop out or does it pop when you're push off a chair? And he said no.
So I didn't examine for stability. And then in the management discussion, why didn't you examine for stability? I kind of looked confused and said, how would you? How would they ask me, how would you do it? I showed them how I would do it because so why you didn't do it? I said, well, he didn't complain about stability. I know the images show instability, but the patient's presentation is not instability.
I got off the hook straightaway because I've done that. Does that make sense? That's for sure. And that's a good example of how a logical higher order of thinking approach and approach the examiner who possibly knew why you didn't test for instability, but they wanted to give you the mark for it. And that's why they ask you why.
And obviously that caused the mark. So I think that's show them that you are thinking and using your history to help you with the guide. You think an examination before we have done that, before we move, I think you're going to move now to the second part of this. But I just thought, well, you are in the history because you've been asked this before from the candidate. There are a few candidates who face this problem is when they went for their intermediate or even for a short cases, they've been faced with patients who are talkative and they go on tangents.
This you're asking the question and they, you know, they don't appreciate you are in an exam situation when you have limited, extremely limited time, really. How do you how do you approach that? What was your plan if you get such a patient in exam? What was your plan and how you were going to tackle this? OK, I can I mention that I faced that in the course before the exam and the patient was so talkative. And I became really irritated and I became abrupt.
The examiner in that course took me aside afterwards, he was really kind to me, and he said, all your colleagues did it better. They did not get it, got a full history, but they were nice to the patient. They tried to get as much information as they can without interrupting, without being rude, without looking irritated. And we know as examiners that these patients are difficult.
We take that into consideration when marking you. So the most important thing, according to his advice, was be considerate to the patient. They know that you will face these patients in the clinic. These patients will take triple the time that you need, but get as much information as you can without irritating them and the rest they will tell you. And in the exam, I had a patient like that. It wasn't as much talkative, but the examiner said, no, no, no, don't go down that route.
Just focus on this. And the patient. The examiner interrupted and gave me the answer. The other thing would be not to ask open ended questions to go with closed ended, and the best way to do that would be to familiarize yourself with the schools like the Oxford hate school school, the shorter school, and try to make a couple of sentences in which you can wrap these schools up.
If you ask them, can you go upstairs? Can you take a shot? Can you get dressed? Can you use public transport? Can you drive? Can you sleep? Do you sleep well at night? So that kind of encompasses everything. And it looks good as well that you are familiar with that scoring system and it can gain you mass marks.
Yeah, thank you. I think, yes, that's a tricky situation because we need to be polite to the patients, definitely. But we I think we will have to take control of the situation and we have to show the examiners that we can control the patient. We can take the conversation in our direction. You don't have to be abrupt, but you could be a little bit firmer with the patient.
Nicely explain to them that I'm very interested in listening to you, but we have limited time. If you don't mind, can we focus on this? See if you can cope in a standard case they're testing to see? Can you think on your feet? Can you manage difficult patients? Can you manage difficult situations or complex situations?
The first, I just a slight disagree. I have trouble with public transport and dismiss that part of sorry, not dismiss, but move on to the next part. But your examination, your examiners will know you have a difficult patient if they tend to talk initially for about 30 seconds and get a feel of what the patient is like. Sometimes the patients are very timid.
They will not volunteer information. Some people talk a lot. You get an idea what your patient is like and then control your conversation with close ended questions. I think that is one way of dealing with it. The alternative or the other scenario is, as you said, the patient who does not talk at all, who you have to milk the information out from. And again, it is another challenging case.
And these are patients we see in the clinic. And this is the time in the clinic is where you practice timing yourself and getting as much of the history without offending the patient in as little time as possible. But it is, as Siobhan was saying, and as everyone was saying, it is part of the exam. Getting this information from a difficult patient is the exam. It's not only getting the diagnosis, it's how you handle the patient.
The most important thing is don't offend them or make them look like, you know, don't make them feel that you are irritated by them, then because you have a duty of care to the patient. So if they're presenting to you in a clinic and they're not giving you the important history that you need to know, you have a duty to get that information. And that's what they're testing. I'm going to talk about the clinical bit.
OK, now, as we said earlier, in the intermediate case, the whole thing hinges on taking a proper history. So focus your examination based on the History you've taken and a tiny bit around it because any of us can make the wrong assumption immediately. And that's why I stressed in the history taking that you are not reaching a diagnosis, you are reaching a differential diagnosis with one likely diagnosis, and your examination is to make sure that diagnosis is correct.
So even when you go there, you go with an open mind check with. There is a scar that does not match the history you taken. Check that the findings exactly match that because he may have that diagnosis, but in addition, he has a nerve problem or previous infection or another joint that is diseased as well, and that will affect how you deal with it. The best example is you go there examining the ankle, which has arthritis, but then you have to look for the slap subtalar joint because that would affect how you would deal with that.
So that if you missed in the exam, in the history, you find in the examination. The other thing is the examination is not an act. You perform in a way you are not there to show them your mastery of examination. You are doing the examination to confirm the diagnosis, exclude the alternatives and formulate a plan. So you have to do that as quickly as efficiently as possible, while at the same time perform all the relevant tests properly.
OK, so some people go there with the approach that I am a master of doing the length discrepancy and they take their time doing it. You are not there to showing them how you do that. You're there to decide what to do for this operation by doing light and gentle with the patient if the patient complains about you when you leave the room. It is almost a guaranteed fail. He was rough.
That's it. You failed. So be gentle, be very polite to the patient, be appreciative and at the same time, make sure that you maintain their dignity and make them see that you are doing that, ok? And be systematic. We all know how to examine, and you will have a chance to do to practice the examination.
You have to have a system in your mind. Next, it's a personal exam. It's personal for you, it's personal for the patient, it's personal for the case. Don't go with a rigid mindset that always I will examine like this. Be flexible. So the tests you have to do, you know, roughly the order, you have to do them, but be flexible and adjust according to the patient's condition.
Although this is like a driving test, so every test you do, you have to slightly exaggerate to make sure that they see you do it and they see you do it properly. One other trick that I would add is can always say I would have done this test, but because of the short of time, I'm going to miss this or I will do it at the end or something along these lines. Now, if they want you to do it and they want you to see you doing it, they will say, no, no, I would like you to do it in front of me.
Or they would say, OK, fine, that's fine. Move on. OK any comment, guys? The last point that you mentioned, is a very valid point, you cannot do possibly do all the tests or all the examination of the patient. You can always volunteer by saying that my approach will be to do this, this, this and this. If the examiners want it, they will ask you to demonstrate that.
And another thing is like, you know, be very interactive with the patient, you always talk to the patient. If if you are not able to see a scar, you can ask the lady will ask the patient whether you had a surgery done here, if the scar is faint and you very clear instruction to the patient. Because when you practice with your colleagues that your colleague will obviously know what will be the next step.
And you will just volunteer without even you giving a clear instruction in that manner. So in exam situation with patients, give very clear instructions. Keep the examiner also involved with the examination. Tell and express what you are doing and why you are doing it. Keep talking along with your examination. I think these are a few points that I would like to add. Thank you.
I think I agree with you, but giving patients clear instructions and the practice that in clinic so you don't have to repeat it to the patient twice, you're losing time. So make sure you understand what you mean by each test, what, what they want, what they understand, what you want from them. So what is clear instructions to patients? Second is clear description of your findings to the examiners.
So if you describing examining an ACL, make sure you clearly tell the examiner there is an ACL laxity on my examination. Don't start telling them. I don't know. Positive and negative tests and stuff like this because it is confusing what is positive and what's negative. So make it clear there is reduced row echelon.
For example, there is value Kessler axilo the virus laxity. Just make sure it's described clearly to the examiner. There is no I would avoid these things like positive Thompson test or positive things and that because people might be confused with positive and what is positive, normal or positive is abnormal. You know, some people can get confused with that. The other thing is that when you go into these examinations, especially your short cases, the rooms are very small.
You would have to examine sometimes an assessor there as well. So it's best to make the patient move rather than you guys move around the patient. That's one thing. The other is when you are doing a foot and ankle examination or any examination, always try to look for walking, engage, look at or take it out, have a look at it and then explain it.
What what it is. If it's soft, if it's hard, if it's accommodative, corrective. And the other thing is, if you need to do a test, there is not enough space or the couch is not perfect. Like in my hip examination, I was going to do the check for any fixed flexion deformity of the Thomas test, and I said, I'm going to I need the couch flat and examine it. Flatten the couch for me.
Because it was a different kind of culture, didn't know how to work it, if I wouldn't have bothered with that and just did it. Maybe you wouldn't have fooled me, but I did the test only. If there is something, be confident, ask for it and look for things and clues. And that's why a system is very important. You need to practice your system again and again, so you don't miss things.
Taking it from Usman, what I have been told and advised in all the courses is you go to the room, you own the cubicle, it is your clinic, you decide whatever you want, you want, you want something brought you bring it, you want the patient standing. You stand here, you want you, you want yourself to sit down, you sit down, OK. You change the room the way you want it, and they appreciate that it means you are confident.
You know what you want. They want someone like that. You adapt to all the situations and take, as Abdullah said, take control of the situation. It's your five minutes with that patient. You can. You have another chance. Another chance is going to be next to them. So that's.
You know, that's your five minutes. OK, I'll move on to the short cases because the technique will be slightly different for them. Mostly, these are spot diagnoses. However, these days, as chika was saying, the boundaries are a little bit blurred. So some of the cases that I had in my short case would have been more suited for an intermediate case and vice versa, for example.
You have to adapt. Most of these are spot diagnoses. These short cases, and if that is the case, you deal with it as it is. So start by inspection and the vast majority of these can be diagnosed by inspection. So you start by thorough inspection, front, back, side scars, joint above and joint below. And usually you would have reached the diagnosis by then.
Just say it. These are the findings. OK, so it's bilateral poly arthritic changes with small joints of both hands. Consistent with rheumatoid arthritis. Full stop. These are systematic changes in the joints bilaterally with skin, nail with nail bed changes and patches over the elbow.
This is psoriatic arthritis, so don't waste time, you know, beating about the Bush. You don't have time to do that quickly. Spot diagnosis 30 to 60 seconds describing what you see. Tell the diagnosis or you say likelihood is this or that, and then you move on to the rest of the examination. And then the examination again, is to focus and confirm your diagnosis and formulate a plan. This is a drop rate consistent with radial nerve injury.
OK muscle wasting, whatever. Ulnar nerve injury. And then you go and examine the joint above and examine the neck, whatever. And during your examination, you focus on the thing that will change your management or give you aid to the management. For example, if you are going to do a donated, you know, a tendon transfer or something like that, you check the tendon you are going to transfer.
But then you proceed as if you do with the intermediate case. OK so any remarks, any comments, guys? Yes, the short case is they are basically spot losers. In the best way to prepare for them is to go through the scrimmage and make a list of the short cases. You can find the common ones in foot, in hand, in shoulder and you practice it is by case in your group. And if you are faced with something that you haven't seen before, just like, for example.
So that's the safe, systematic approach and he was happy with you don't be faced with anything that you haven't seen before. If all of a sudden that comes, just follow a system and be safe and be systematic. And if you don't know about it, just say I haven't seen this thing before, but this is how I'm going to go about it. I think the short cases are really difficult and tricky, and most failures happen here.
And it's one of the difficulties is, as you say, do you have only two to three minutes maximum three minutes, three to examine the patient, you really have 2 minutes only because you need to reach a diagnosis and you need to start the specific management plan within just five minutes. So one of the difficulties in the exams that maybe you could enlighten us on, how would you approach is you get into a cubicle and the examiner, then you examine this lady's legs.
How would you approach that in a short case scenario when you don't have the time to determine the latest speedy? The short case is actually it's a very varied kind of cohort, so basically you can have a very poor diagnosis like a pre axilo deficiency of the pollen where it is just looking at it. You know what it is, or it'll be like a rotator cuff tear of the shoulder where you just be instructed to examine the shoulder.
So the key thing is to get maximum time and take your day. Take the time deep into the discussion in the management. So take it deep in the discussion part. So you have to find a way of dealing with it. So if it is a sport diagnosis, you say what it is. And so you have enough and more time to discuss about it. But certain situations like an elbow examination or a shoulder examination, first, we need to find out.
You need to get your diagnosis in around two to three minutes. Make sure that you have got at least two minutes to discuss the case. Don't keep on examining the joint in about four minutes, five minutes. And that discussion happens in the corridor when you go to the next case. So so it's a very variable cohort and you need to find a way of trying is to give people advice on that way.
What is the way, for example, I think I would recommend that you ask patient one or two questions before you examine them in the short piece. So if you go into a cubicle, you find a young patient, ask you to examine the shoulder. You're not going to do full further examination. You know, young patient is going to be faced with instability, most likely. So you ask the patient.
Does the shoulder is unstable or pops out? There's no harm in asking them if they want to stop you, they'll stop you, and then the patient will say yes, most likely. And then what you focus on for the short cases. If you find them, what's the problem? The excuse you give is I do not want to dislocate their shoulder in the clinic. And that's a very valid excuse.
Ok? he's done. He's coming with a shoulder problem. I don't want to dislocate his shoulder. It's like when you examining a joint, you say, where does it hurt? So it's the same thing. You don't want to have the examination in the short cases. Yeah, that's the passage really tailor the examination. So they're not examining being full examination, state examination and shoulder instability.
Alex Vargas. There is no time to perform full examination and you're not expected and please don't do full examination in the short cases. Stay alert, focused examination on the specific condition, and I don't know if they were happy. The other thing I said before, if you're stuck, there is no problem in sharing your thoughts with the examiners because that's what they want to hear.
They want to see your thinking process, ok? They want someone who is safe, logical and systematic. Give them that and they will pass you. So think logically, think systematically and think loudly. And they will be your side. On your side, that's almost done, one more thing I would like to add, which I did not mention when you do the examination, what I did personally is I made a small cards like that, like four can fit in a four page for each joint.
You have a small box and you do that, practice it. And I just borrowed that from petoskey and Faisal Ali. And you just read them and you practice on them and you carry them around. And one by example for the courses, it's better to attend the courses that have got the technical component in it. Then you can go and you can see these weird and wonderful pathologies that would help you in diagnosing things, open up your mind a bit and give you some confidence as well.
If you're thinking about courses, go for courses that have good clinical components with it. So good night, guys. Good NIPE. I love.
Segment:0 .
Not us. Thank you, everyone, for coming today. First of all, I would like to congratulate everyone who passed the recent exam. Either part one or part two annotation will help you focus a little bit on what might have been wrong or what you could have done to pass it this time.
So again, what is this talk about? It is my approach to the exam, and during this presentation you would find that some of my colleagues would mention slightly different approach in certain aspects. There are many ways of skinning a cat. No one correct way. You have to find your own way. But I'm just presenting my experience and you can take whatever you find useful from that.
What is this presentation, not I'm not going to tell you how to examine a joint or how to take a history. OK, you've been doing orthopedics for many years. All of us. And this is not the chance to do that. But what I'm going to tell you is how I approached the exam as a task and how I did to get this task done with the minimal effort possible.
Ok? and I will guide you. I'll tell you where you can get more information or more experience. In fact, tirath told us to choose the clinical part because this is the part that is neglected during all the sessions we do in this and many courses neglected, although the clinical part is half the exam Hall presentation.
And I think if you can take one thing, one sentence from the whole presentation is planning is everything. You have to plan and you have to plan early and you have to plan correctly, and you have to put timescale into that plan. You have to know how many months you have into that exam and what are you going to do in each month until the exam? And you can score more in the clinical that's compared to the virus.
And if you practice these clinically well and stick to your system, you would find what the positive findings are in the patient. You can present them and then that's how you are going to score. But your technique is going to be different. Not everybody is the same way. But make sure that you take all the boxes, you do all the relevant tests and you don't miss out on anything.
And if you see something positive, just say it did and go for the kill. Like, for example, if you see a cable for, say, it's a giveaway to sport and then move on and do other things, OK, fine. So we'll get to that. So but we agreed. Now the clinical and I agree with Abdullah is more important than survivor.
Most of us pass or fail on the clinical day. So the first day of the exam, and we don't give that enough attention as much as we give to the Viva. OK, so the next point I would like to make is, what is your target? OK, what are you aiming to achieve, what the examiners want to see in you? The most important thing is they want to see a colleague.
Ok? the farke's the fellowship is a club. They will not invite to the club, and anyone who doesn't look like the rest of the members of the club looks like them. Behaves like them. Talks like them. And that's what you want to achieve. Look at your consultants.
Imitate them. OK, this is what you want. The next thing and I tried to put them in order of importance, the next important bit is that you need to be safe. They want someone who is really safe in handling patients. They don't want someone who would bring their trust complaint after complaint. OK they want someone who is confident.
Whatever you say, say it confidently. Most likely, you will be right, ok? But if you sound hesitant, you make the decision in a hesitant way. They would think he's just looking. He's just, you know, hazarding a guess. Whenever you're stuck and you will be stuck in the exam, believe me, I've been there and I've been stuck several times just to be systematic and logical.
What I mean by that is have a system you fall back into. For example, if you are listing the causes of something, have a system, either you would say it could be congenital, it could be traumatic, it could be endocrine, it could be whatever. OK, that's one system. The other system is it could be acute and chronic as long as you have a system to fall back to. They will be happy as long as you make a logical decision and make sure that they listen to the decision process.
For example, in the exam, I had a patient with a funny diagnosis. She had a hand that she could not move with muscle wasting. So I said she has sensation. But inability to move so it cannot be completely neurological, so it's either only motor. Or something else muscular? Now I was unable to move the joint, so it's not muscular and I was saying that loud, so he said correct.
What could it be? It took me a bit and then I said it's after process. And he said, Yes. Correct Yeah. Excellent example. Yeah next, they want someone who can cope with variations, either variations in presentation or variations in management, so be prepared to have a slightly wider scope of thinking.
Don't go just this is a practice. I need to do a joint replacement. Make sure that you have a broader view of the condition and the patient and the most important thing and the thing that a lot of us will fail with is the familiarity with the UK system, especially people who hasn't been in this country for very long. OK they don't want someone who would practice American or European or Middle East or Indian medicine.
They want someone who would cope well with the UK system. OK and the last bit and I made sure that it is the last bit. They want someone who is knowledgeable, ok? Everyone says you've proven that you are knowledgeable by passing part one. They don't want your knowledge. They want to see that you can use that knowledge to help the patient. OK and that's what they want.
Any other points, Usman or GQ that you think that they would look for in the candidate? Yeah I think like, no, you should be very sleek and very systematic. So rightly said so you should. We should have your method of expressing a particular information across your. You might not have to list it all the 10 causes of particular of your particular condition, but you should be very systematic and organized the way that you are putting it and in clinical and you should be very, very sleek when you are looking examining the pieces.
OK, so the next how I did that. So the most important thing is to start early. And by early, I mean, months and months and months in advance and ideally a year in advance. OK, the way you do that is you put a plan. And you start by recruiting your own consultants. The best thing I had is I had a helpful consultant in my trust who took the time off to take us through difficult x-rays and let us talk about them in a systematic way.
And he spent about a year doing that almost once every two weeks, half an hour, every week. The importance is not that the amount of time we do in each session is we are doing it over a long period of time. Now you don't have to have that level of commitment by it from your consultant. All what you need is someone who would take the time and tell you, this is an interesting case.
I would like you to examine it in front of me. Or tell me about how we do approach this condition or during the operation while you are assisting him, take me through the approach of this. The important is you have to have someone who's passed the exam taking you frequently through that over a long period of time. This is the most important thing if you cannot have that, and many people cannot have that.
You should have some point number three. OK and that is for everyone as well. Former group Usman knows he was one of the group we chose. We started early. And we chose a reference on our reference was asked which? We chose that book to cover the whole syllabus. We decided that this is the book we are going to read. These are the chapters, we are going to read. This is the pattern we are going to use.
And that group doesn't have to be in one physical place because one of us was in Birmingham, the other in Scotland, the third in London, and the fourth was somewhere in Nottingham and I was in yoga. You can use Skype. And as long as you have a defined time every day or every other day, you find no and you start again, then did it again. And the most important thing is we implemented that in the clinic.
But they want to see in the exam is what you do in your clinic, and it'll show. Believe me, if it is the first time you're doing it in the exam, they know if it is only the fifth time they know it will look. You cannot hide that. You have to have done this in the clinic with patients. Tens of times for it to look slick. OK the other thing is, there is no time in the exam to think of the next step.
You have to have done this so that it becomes like a second nature to any exam is study the same way you are expected to be presented. So for a clinical examination, the best preparation is examine a colleague, examine a patient and see someone examining their OK because this is the fastest way of what they call it, a muscle memory. So it becomes like a muscle memory, you are doing it in the exam as natural as you would do it in the clinic.
Again, I will stop and cosmological. And I think this is very important that you make your system and you practice it when you are doing your clinics in the hospital. Like if you are practicing it on each other, it's easy. You have done those examinations and the other person who is mimicking the patient. And if what you're asking him to do, if you try that on a patient in the clinic, it's a completely different experience.
They are not familiar with the examination. And that's the time when you get your confidence, when you do it again and again in clinic. And that's basically what I did in my fracture clinics, in my elective clinics. I examined the hips, knees, elbows, shoulders, all these joints. I did it repeatedly on the patients and that kind of ingrained that reflex action that if you are asked to examine a hip or elbow or the knee, you start doing it, but do it in a formal session.
And in the end time as well. Yeah, so this exam is not an exam that you can go solo because I have prided myself a couple of times and I failed miserably and I've got a by God's grace, I got a good partner and we studied together. So when you study with your colleague, you will reach one particular level.
Then you discuss that particular topic with one of the specialists in that field, and your knowledge will go one notch higher about 4 to six months to the exam. What you can do is every clinic session that you are attending. Choose one or two cases, which it can be any case, but tell the patient that we are going, you are going to take an exam. I want to take a 5 4 minute history from you.
Then I will summarize your findings to you in about one minute, then stick on to the 5 minute examination and up and present your history and examination to your senior colleague or one of the specialists that is helpful to you and take the discussion from there. I think that I found it very helpful. I think that's very helpful, but I would advise colleagues that when you do that, don't have a look at the notes or x-rays.
You just go pick any patient randomly from people waiting and bring them to the room and start from 0. So you will know possibly this is an upper limit or lower limit clinic as an ankle and foot ankle. This information will come to you. You can't avoid it, but don't open the nose or look at the x-rays before examining the patient. So we started all the joints, then the elbow joint, then the wrist joint and the hand, then hip, then knee just normal joint on each other.
And we kept repeating that until it. A second. Then we moved to examine the joints as if it's an intermediate case as you do the whole. All the tests that takes a lot of time. You do that until it becomes a second nature. And the way we did it initially is on each other pretending to be patients, pretending that there are some findings, but then you move on to examine it on patients once you have a chance.
Ideally, you should be able to do that every week, as you said in the clinic. But then it is. We're doing it in front of each other so that there is someone who is stabbing you, correcting your mistake at once. We must address you to do the examination as if it is a short case. Ok?
and there is a difference between the two techniques. The first technique. You do it properly. You do all the tests. The second technique, you have to immediately choose which tests you have to omit. Which tests you have to do very quickly because all what you have is about two to three minutes. During that time, you have to have finished your examination, presented them and ready for them to ask you, what are you going to do with this patient?
This doesn't work for every joint or for every case. But if you practice it enough, it would be good for you if you will cover the majority of the exam. And as I said, you have to implement that in the clinic. We had the time as every case, every examination should not take more than five minutes. OK and we use video, so one of us will be examined, the other one will be examined and the third is holding a video.
We did not take a about practicing it and be doing yourself. We tried that as well, and I think it really helps. You can see yourself what you are doing and you are your best critic and you can iron out the problems that you are having by watching yourself and doing it. What is my body language like? How am I standing handling the patient where my hands are? It's all about refining that performance.
You are giving a performance on that day. So it's all about that, and the more refined you are, the better you will score. OK so the next is the exam itself. Now you have done all your preparation and you are in the exam, ok? The important thing and I cannot stress this more than, you know, I cannot stress this more.
The saying is those who fail to learn from history are doomed to repeat those who fail to take a proper history to repeat the exam. I think all you take, all your clinical examination hinges on taking a proper history and from getting some feedback of people who failed in the past the majority of the time. The problem is either the assumed that the diagnosis is something because they did not take a proper history and they went to the examination to prove that while it is completely different, I'll give you an example.
One of my colleagues failed the case because ask about infection and assume that it is a dysplasia, while the problem had a previous infection in the hip joint. So that destroys the whole case. OK, I'm sure he felt because of that. If you do not take a proper history, you might as well go home. OK, next, which is very, very important, this is another failure point.
Respect the patient. We don't handle them roughly. Don't talk town down to them. Thank them when they come and thank them when you leave. They have taken some of their time to come and help you be seen to be polite to them and appreciative of what they do. OK but at the same time, don't let that hinder you from getting what you want to get, which is a proper history and proper examination.
So deal with them as if you deal with them in the clinic. Very polite, very professional. But to the point there isn't enough time to talk about their dog or what they had for lunch or things like that. The next point can be controversial, and I'm saying it deliberately aim to get the differential diagnosis, not only one diagnosis.
OK the reason I say that is I've seen many of my colleagues. They're the first couple of sentences from this story. Make sure that, you know, they get a diagnosis and they stick by it and assume it is correct and they run with it. If you take the history you say, for example, this is likely to be arthritis. However, I may need to exclude infection. I may need to exclude pain coming from the spine.
And you go to the examination to exclude those two things. You will not be mistaken if you go back to the example I gave earlier, my colleague who assumed that it is simple arthritis and forgot about the infection. We have that made that mistake if he had a slap road in mind. So this is likely to be arthritis, but I have to exclude infection. OK, next, while you're taking the history, it's not only about what problem.
They make sure that you look into things that would alter you management, for example, does the patient have other medical problems that would stop you from having the operation? Does do they have? Did they have an operation before? What sort of treatment they had? Are they willing to have an operation or not? OK The most important thing, again, is listen carefully.
Believe me, they will drop you hints right, left and center. It is your duty to take them. Really? listen carefully. The patient will tell you, the examiner will tell you. And when you say something wrong and look at the patient a lot of the time, they sympathize with you and they want you to pass. And you can see from their reaction that you've missed something.
So be attentive, ok? Next is be systematic in your history, if you jump right, left and center, you will score badly and you will likely to miss points. Start with the I mean, we all know how to take a history present complaint. You know, talk about the present complaint. Are the complaints, other systems, you know, we know how to do that.
The next thing is, don't forget infection, prevent infection and previous infections and clotting again, whether they are on anticoagulation. And the risk factors for DVT. These can be used to because if the patient has already some infection somewhere and you offer them an operation that you may kill them, so be careful with that. Any practical points from the history taking in the exam, guys Chico and Usman.
Yeah, so now I don't know whether it was like that before, because why? What I have noticed now is that there is a lot of crossover of cases now. Previously, like we thought, like intermediate cases will be a hip case or a spy case or a shoulder case or any case. But for me personally, I have got like this, this exam. I got a pigment that we don't know where it is of the finger, which is a small, tiny swelling in on the camera aspect of the proximal phalanx.
And you have to take you have to ready to take a history, a five minute history and do a five minute examination on that particular patient. Another time I got a post-traumatic likely a snack or a slap, which if you are not ready to take a history or terrorist case, you will be found stuck in that particular situation, so you should be ready to take history in any case. So don't think that, like you know, the intermediate cases will be all the standard cases which we think about.
You should be ready to take history in any case. So there is no compartmentalization between the intermediate and the shortest. That's true. That's true. I think that's very, very important. I think that's the value of having you guys who are fresh because I think the previous understanding is that an intermediate case has to be hip.
Arthritis has to be knee arthritis, ankle spine. But as you explained, it could be anything could be condition a simple thing or simple hand, or even could come as an intermediate case. So thank you on the hand by our table, and we don't emphasize so much on history taking. You can gather a lot from your history and you can score a lot of points from your history if you are presented with the problem you face if you haven't seen it before.
Ask about the problem. When did it start? How was the patient? How did the patient become aware of it? What if he had any treatment for it, but tried so far all these things? Then the next thing you can ask is how did the patient, their occupation, the day to day life, the sleep, walking all of these things?
And then you move on and you ask about the past medical history. But if you get anything positive in the history, like if the patient tells you you've had any surgery, then try digging into it and ask them, when was this? Why was it done? Were there any complications like, for example, I had my intermediate case. There was a child who was 62 years old and he had a problem with his hip.
And I asked him in the first thing he said to me, I had a hip replacement 20 years ago, so that would ring a bell. This chap had a hip replacement at the age of two, must have had some problems with the. And that led on to the discussion here 30 of the. And so you need to find those things out and you need to go in with an open mind, but you need to have the system for your history. I think most of us, when we practice for the clinical, we skip the history taking.
We think it's the easy part is the most important bit. Exactly you'd be surprised how many people fail in the history, and it's shocking because you think a doctor at this stage, history making history is the easiest, but it has to be focused, specific history, taking with the limited time and focused helping you find the diagnosis and the management. And I just think when I was practicing, I could add to people advice here.
I practiced that. The last question I ask in the history at the end of the five minutes is to ask the patients, what are your expectations and what are you? What do you hope to achieve from this consultation? And I think if the patient is on your side, you'll be surprised what information you get from this. From this asking this question, if you've been good to the patient and the patient likes you, they can at this stage give you information you might have missed during the whole history taking.
So I think variation of that question is summarizing to the patient and then say, what have I left out anything? Is there anything you'd like to add? And then you expect this from today's consultation if they say, no, no, no, I don't want an operation I want, then you've got your pathway set up already by the patient and the patient will tell you you've missed something in. Yeah, I forgot to tell you, I'm on anticoagulation, but does that make sense?
Or you might have forgotten that, she said. They're on anticoagulation. It could be something very subtle that is very important. And I apologize. I have you covered it very well. There is a couple of other things in the history, which I think is very good to put in things like are you a smoker? Are you on blood thinners or you have any heart problem, breathing problem?
Or are you diabetic or using steroids? Those are Yes and no questions, because if you miss those, your management plan goes down the drain. OK, so I don't. Those I consider quite important. Just as the end part, just before you start to summarize to the patient what you found. I know it's hard to include all of this in your five minutes and to reinforce what Abdullah jaka and Mohammad one said they are.
The history sets you up for the rest, we talk about independent marketing opportunities. What if you don't do the history correctly, you're not going to get the marketing you need in the examination because the and you're never going to get to the management because if your history, the patient or an infection, there's no you're going to miss the scar that's potentially looking with a sinus.
This might miss the patient complained of stiff elbow decreased range of motion. The injury led to instability of the elbow, but he becomes so arthritic that it became a stiff elbow. So when I did my examination, I didn't examine for instability because I specifically asked them the history does your knee pop out or does it pop when you're push off a chair? And he said no.
So I didn't examine for stability. And then in the management discussion, why didn't you examine for stability? I kind of looked confused and said, how would you? How would they ask me, how would you do it? I showed them how I would do it because so why you didn't do it? I said, well, he didn't complain about stability. I know the images show instability, but the patient's presentation is not instability.
I got off the hook straightaway because I've done that. Does that make sense? That's for sure. And that's a good example of how a logical higher order of thinking approach and approach the examiner who possibly knew why you didn't test for instability, but they wanted to give you the mark for it. And that's why they ask you why.
And obviously that caused the mark. So I think that's show them that you are thinking and using your history to help you with the guide. You think an examination before we have done that, before we move, I think you're going to move now to the second part of this. But I just thought, well, you are in the history because you've been asked this before from the candidate. There are a few candidates who face this problem is when they went for their intermediate or even for a short cases, they've been faced with patients who are talkative and they go on tangents.
This you're asking the question and they, you know, they don't appreciate you are in an exam situation when you have limited, extremely limited time, really. How do you how do you approach that? What was your plan if you get such a patient in exam? What was your plan and how you were going to tackle this? OK, I can I mention that I faced that in the course before the exam and the patient was so talkative. And I became really irritated and I became abrupt.
The examiner in that course took me aside afterwards, he was really kind to me, and he said, all your colleagues did it better. They did not get it, got a full history, but they were nice to the patient. They tried to get as much information as they can without interrupting, without being rude, without looking irritated. And we know as examiners that these patients are difficult.
We take that into consideration when marking you. So the most important thing, according to his advice, was be considerate to the patient. They know that you will face these patients in the clinic. These patients will take triple the time that you need, but get as much information as you can without irritating them and the rest they will tell you. And in the exam, I had a patient like that. It wasn't as much talkative, but the examiner said, no, no, no, don't go down that route.
Just focus on this. And the patient. The examiner interrupted and gave me the answer. The other thing would be not to ask open ended questions to go with closed ended, and the best way to do that would be to familiarize yourself with the schools like the Oxford hate school school, the shorter school, and try to make a couple of sentences in which you can wrap these schools up.
If you ask them, can you go upstairs? Can you take a shot? Can you get dressed? Can you use public transport? Can you drive? Can you sleep? Do you sleep well at night? So that kind of encompasses everything. And it looks good as well that you are familiar with that scoring system and it can gain you mass marks.
Yeah, thank you. I think, yes, that's a tricky situation because we need to be polite to the patients, definitely. But we I think we will have to take control of the situation and we have to show the examiners that we can control the patient. We can take the conversation in our direction. You don't have to be abrupt, but you could be a little bit firmer with the patient.
Nicely explain to them that I'm very interested in listening to you, but we have limited time. If you don't mind, can we focus on this? See if you can cope in a standard case they're testing to see? Can you think on your feet? Can you manage difficult patients? Can you manage difficult situations or complex situations?
The first, I just a slight disagree. I have trouble with public transport and dismiss that part of sorry, not dismiss, but move on to the next part. But your examination, your examiners will know you have a difficult patient if they tend to talk initially for about 30 seconds and get a feel of what the patient is like. Sometimes the patients are very timid.
They will not volunteer information. Some people talk a lot. You get an idea what your patient is like and then control your conversation with close ended questions. I think that is one way of dealing with it. The alternative or the other scenario is, as you said, the patient who does not talk at all, who you have to milk the information out from. And again, it is another challenging case.
And these are patients we see in the clinic. And this is the time in the clinic is where you practice timing yourself and getting as much of the history without offending the patient in as little time as possible. But it is, as Siobhan was saying, and as everyone was saying, it is part of the exam. Getting this information from a difficult patient is the exam. It's not only getting the diagnosis, it's how you handle the patient.
The most important thing is don't offend them or make them look like, you know, don't make them feel that you are irritated by them, then because you have a duty of care to the patient. So if they're presenting to you in a clinic and they're not giving you the important history that you need to know, you have a duty to get that information. And that's what they're testing. I'm going to talk about the clinical bit.
OK, now, as we said earlier, in the intermediate case, the whole thing hinges on taking a proper history. So focus your examination based on the History you've taken and a tiny bit around it because any of us can make the wrong assumption immediately. And that's why I stressed in the history taking that you are not reaching a diagnosis, you are reaching a differential diagnosis with one likely diagnosis, and your examination is to make sure that diagnosis is correct.
So even when you go there, you go with an open mind check with. There is a scar that does not match the history you taken. Check that the findings exactly match that because he may have that diagnosis, but in addition, he has a nerve problem or previous infection or another joint that is diseased as well, and that will affect how you deal with it. The best example is you go there examining the ankle, which has arthritis, but then you have to look for the slap subtalar joint because that would affect how you would deal with that.
So that if you missed in the exam, in the history, you find in the examination. The other thing is the examination is not an act. You perform in a way you are not there to show them your mastery of examination. You are doing the examination to confirm the diagnosis, exclude the alternatives and formulate a plan. So you have to do that as quickly as efficiently as possible, while at the same time perform all the relevant tests properly.
OK, so some people go there with the approach that I am a master of doing the length discrepancy and they take their time doing it. You are not there to showing them how you do that. You're there to decide what to do for this operation by doing light and gentle with the patient if the patient complains about you when you leave the room. It is almost a guaranteed fail. He was rough.
That's it. You failed. So be gentle, be very polite to the patient, be appreciative and at the same time, make sure that you maintain their dignity and make them see that you are doing that, ok? And be systematic. We all know how to examine, and you will have a chance to do to practice the examination.
You have to have a system in your mind. Next, it's a personal exam. It's personal for you, it's personal for the patient, it's personal for the case. Don't go with a rigid mindset that always I will examine like this. Be flexible. So the tests you have to do, you know, roughly the order, you have to do them, but be flexible and adjust according to the patient's condition.
Although this is like a driving test, so every test you do, you have to slightly exaggerate to make sure that they see you do it and they see you do it properly. One other trick that I would add is can always say I would have done this test, but because of the short of time, I'm going to miss this or I will do it at the end or something along these lines. Now, if they want you to do it and they want you to see you doing it, they will say, no, no, I would like you to do it in front of me.
Or they would say, OK, fine, that's fine. Move on. OK any comment, guys? The last point that you mentioned, is a very valid point, you cannot do possibly do all the tests or all the examination of the patient. You can always volunteer by saying that my approach will be to do this, this, this and this. If the examiners want it, they will ask you to demonstrate that.
And another thing is like, you know, be very interactive with the patient, you always talk to the patient. If if you are not able to see a scar, you can ask the lady will ask the patient whether you had a surgery done here, if the scar is faint and you very clear instruction to the patient. Because when you practice with your colleagues that your colleague will obviously know what will be the next step.
And you will just volunteer without even you giving a clear instruction in that manner. So in exam situation with patients, give very clear instructions. Keep the examiner also involved with the examination. Tell and express what you are doing and why you are doing it. Keep talking along with your examination. I think these are a few points that I would like to add. Thank you.
I think I agree with you, but giving patients clear instructions and the practice that in clinic so you don't have to repeat it to the patient twice, you're losing time. So make sure you understand what you mean by each test, what, what they want, what they understand, what you want from them. So what is clear instructions to patients? Second is clear description of your findings to the examiners.
So if you describing examining an ACL, make sure you clearly tell the examiner there is an ACL laxity on my examination. Don't start telling them. I don't know. Positive and negative tests and stuff like this because it is confusing what is positive and what's negative. So make it clear there is reduced row echelon.
For example, there is value Kessler axilo the virus laxity. Just make sure it's described clearly to the examiner. There is no I would avoid these things like positive Thompson test or positive things and that because people might be confused with positive and what is positive, normal or positive is abnormal. You know, some people can get confused with that. The other thing is that when you go into these examinations, especially your short cases, the rooms are very small.
You would have to examine sometimes an assessor there as well. So it's best to make the patient move rather than you guys move around the patient. That's one thing. The other is when you are doing a foot and ankle examination or any examination, always try to look for walking, engage, look at or take it out, have a look at it and then explain it.
What what it is. If it's soft, if it's hard, if it's accommodative, corrective. And the other thing is, if you need to do a test, there is not enough space or the couch is not perfect. Like in my hip examination, I was going to do the check for any fixed flexion deformity of the Thomas test, and I said, I'm going to I need the couch flat and examine it. Flatten the couch for me.
Because it was a different kind of culture, didn't know how to work it, if I wouldn't have bothered with that and just did it. Maybe you wouldn't have fooled me, but I did the test only. If there is something, be confident, ask for it and look for things and clues. And that's why a system is very important. You need to practice your system again and again, so you don't miss things.
Taking it from Usman, what I have been told and advised in all the courses is you go to the room, you own the cubicle, it is your clinic, you decide whatever you want, you want, you want something brought you bring it, you want the patient standing. You stand here, you want you, you want yourself to sit down, you sit down, OK. You change the room the way you want it, and they appreciate that it means you are confident.
You know what you want. They want someone like that. You adapt to all the situations and take, as Abdullah said, take control of the situation. It's your five minutes with that patient. You can. You have another chance. Another chance is going to be next to them. So that's.
You know, that's your five minutes. OK, I'll move on to the short cases because the technique will be slightly different for them. Mostly, these are spot diagnoses. However, these days, as chika was saying, the boundaries are a little bit blurred. So some of the cases that I had in my short case would have been more suited for an intermediate case and vice versa, for example.
You have to adapt. Most of these are spot diagnoses. These short cases, and if that is the case, you deal with it as it is. So start by inspection and the vast majority of these can be diagnosed by inspection. So you start by thorough inspection, front, back, side scars, joint above and joint below. And usually you would have reached the diagnosis by then.
Just say it. These are the findings. OK, so it's bilateral poly arthritic changes with small joints of both hands. Consistent with rheumatoid arthritis. Full stop. These are systematic changes in the joints bilaterally with skin, nail with nail bed changes and patches over the elbow.
This is psoriatic arthritis, so don't waste time, you know, beating about the Bush. You don't have time to do that quickly. Spot diagnosis 30 to 60 seconds describing what you see. Tell the diagnosis or you say likelihood is this or that, and then you move on to the rest of the examination. And then the examination again, is to focus and confirm your diagnosis and formulate a plan. This is a drop rate consistent with radial nerve injury.
OK muscle wasting, whatever. Ulnar nerve injury. And then you go and examine the joint above and examine the neck, whatever. And during your examination, you focus on the thing that will change your management or give you aid to the management. For example, if you are going to do a donated, you know, a tendon transfer or something like that, you check the tendon you are going to transfer.
But then you proceed as if you do with the intermediate case. OK so any remarks, any comments, guys? Yes, the short case is they are basically spot losers. In the best way to prepare for them is to go through the scrimmage and make a list of the short cases. You can find the common ones in foot, in hand, in shoulder and you practice it is by case in your group. And if you are faced with something that you haven't seen before, just like, for example.
So that's the safe, systematic approach and he was happy with you don't be faced with anything that you haven't seen before. If all of a sudden that comes, just follow a system and be safe and be systematic. And if you don't know about it, just say I haven't seen this thing before, but this is how I'm going to go about it. I think the short cases are really difficult and tricky, and most failures happen here.
And it's one of the difficulties is, as you say, do you have only two to three minutes maximum three minutes, three to examine the patient, you really have 2 minutes only because you need to reach a diagnosis and you need to start the specific management plan within just five minutes. So one of the difficulties in the exams that maybe you could enlighten us on, how would you approach is you get into a cubicle and the examiner, then you examine this lady's legs.
How would you approach that in a short case scenario when you don't have the time to determine the latest speedy? The short case is actually it's a very varied kind of cohort, so basically you can have a very poor diagnosis like a pre axilo deficiency of the pollen where it is just looking at it. You know what it is, or it'll be like a rotator cuff tear of the shoulder where you just be instructed to examine the shoulder.
So the key thing is to get maximum time and take your day. Take the time deep into the discussion in the management. So take it deep in the discussion part. So you have to find a way of dealing with it. So if it is a sport diagnosis, you say what it is. And so you have enough and more time to discuss about it. But certain situations like an elbow examination or a shoulder examination, first, we need to find out.
You need to get your diagnosis in around two to three minutes. Make sure that you have got at least two minutes to discuss the case. Don't keep on examining the joint in about four minutes, five minutes. And that discussion happens in the corridor when you go to the next case. So so it's a very variable cohort and you need to find a way of trying is to give people advice on that way.
What is the way, for example, I think I would recommend that you ask patient one or two questions before you examine them in the short piece. So if you go into a cubicle, you find a young patient, ask you to examine the shoulder. You're not going to do full further examination. You know, young patient is going to be faced with instability, most likely. So you ask the patient.
Does the shoulder is unstable or pops out? There's no harm in asking them if they want to stop you, they'll stop you, and then the patient will say yes, most likely. And then what you focus on for the short cases. If you find them, what's the problem? The excuse you give is I do not want to dislocate their shoulder in the clinic. And that's a very valid excuse.
Ok? he's done. He's coming with a shoulder problem. I don't want to dislocate his shoulder. It's like when you examining a joint, you say, where does it hurt? So it's the same thing. You don't want to have the examination in the short cases. Yeah, that's the passage really tailor the examination. So they're not examining being full examination, state examination and shoulder instability.
Alex Vargas. There is no time to perform full examination and you're not expected and please don't do full examination in the short cases. Stay alert, focused examination on the specific condition, and I don't know if they were happy. The other thing I said before, if you're stuck, there is no problem in sharing your thoughts with the examiners because that's what they want to hear.
They want to see your thinking process, ok? They want someone who is safe, logical and systematic. Give them that and they will pass you. So think logically, think systematically and think loudly. And they will be your side. On your side, that's almost done, one more thing I would like to add, which I did not mention when you do the examination, what I did personally is I made a small cards like that, like four can fit in a four page for each joint.
You have a small box and you do that, practice it. And I just borrowed that from petoskey and Faisal Ali. And you just read them and you practice on them and you carry them around. And one by example for the courses, it's better to attend the courses that have got the technical component in it. Then you can go and you can see these weird and wonderful pathologies that would help you in diagnosing things, open up your mind a bit and give you some confidence as well.
If you're thinking about courses, go for courses that have good clinical components with it. So good night, guys. Good NIPE. I love.
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