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History and Examination of the Knee for Postgraduate Orthopaedic Exams (Part 1 )
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History and Examination of the Knee for Postgraduate Orthopaedic Exams (Part 1 )
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Language: EN.
Segment:0 .
If you don't mind me, me and Zubin will be there for us. The examiner and my other colleagues will also be the co examiners. So I mean, yeah, imagine this is imagine this is a real exam. You know, it's difficult within the constraints we have. But imagine you are actually entering a cubicle. Yeah, sure, you are in the first case exam. Yes yeah, that's it. And to be taken through to examiners there, someone taking you through the examiner.
Mr and mavela is your examiner here and Zubin is the patient. Balasaheb will come exam I'm your examiner, Mr. Morrison. You have a patient at the moment. We're going to take you to see who is having a problem with his knee. So can you? Yeah can you please come and ask him a few questions? Find out what's going on with him. You have five minutes.
Hello, I'm Mr. Francisco Examiner. This is Mr. Smith. Please carry on. Oh, hi, my name is Saeed. Thanks for letting me examine you. Tell me. How old are you if you don't mind me asking? How old I am, I'm 70, 70 years old, ok? And what seems to be a problem, how can I help you?
Having left me? How long has it been going on for? Thank you. It's for 20 years now, 20 years. OK how it all started. The last 20 years, like it started slowly and slowly, I can hardly hear you. For the last 20 years, I'm having this pain. Yeah so then you left me has got a pain.
Yeah, Yeah. Do you have any full? Yes, I had to fill in. OK when was this? I was driving a motorbike, so like, I just kind of had to wait. So you fell from the motorbike 20 years ago? Not recently. No right?
Was anything done about that? Sorry about that. Yeah I had some painkillers and physiotherapy. That's right. Did you have any fracture was diagnosed at the time? No, not really. Not a fracture. All right. OK any other soft tissue injuries was diagnosed at the time.
Yeah, it was like the doctors told me, like some sort of injury, but I carried on with it, right? So you never say seek any medical attention for it. I went to the doctor, he gave me medicines, I applied some ice and that's it. So did you manage since then well, or is it still a problem? Since then, the beginning, it was less but slowly I'm feeling the pain, right? So your seven year old, you had an injury from the motorbike 20 years ago when you in your age of 50.
And then so did you have a pain? Your pain got better in the meantime. How? you can see that it got better. Yeah, it was like better or it was better was like this kind of thing, OK, so on and off pain, was it actually? Are you off your knee? Give it all.
Yeah, sometimes it gives way a bell. Going downstairs, going upstairs. Yeah well, going downstairs, it gives me. All right. OK, so how do you manage normally, stairs and everything? Recently, I'm feeling more pain. OK, well, climbing down the stairs does your knee. Click the.
It does. Yeah OK. Anything else being done about it at all? Nothing I'm just using a stick now. OK to managing with it. Right, and in terms of the gasoline at all. Yes, intelectual, yes, right, OK. And when you do any tea, what does it stop you doing it? Sorry what stopped you doing that accountability?
Will you be affected? I am not able to play golf. I'm not able to, you know, go to the markets for doing my usual stuff. OK you take any medication for it at all. Yes, I take painkillers on off. OK, any other medical problem you suffer from? Yes, I have like hypertension and diabetes. Diabetes as well in hypertension.
And you take medication for it. Any blood thinners at all? Not really anything allergic to any other medical problem. I need to know. No what are your expectations and what do you want? Is to be done then about that? But I just want to get you to the pain and spend my life pain free. Does this does this pain disturb your sleep in the NIPE at all?
Not anymore. So you are managing with painkillers without disturbing your night's sleep and get the pain at NIPE. It's only like when I walk, then only I get the pain right? And does it? I mean, your hobbies wise, do you work? Do you still work or are you tired? Well, right now? No, I used to work as a plumber, but I left my job because of the pain, because of failure.
OK, any hobbies you still do, which you can cannot manage anymore. I love playing golf, which I'm not able to play now. Right OK, so OK, thank you very much. So let me see, do I have a shot of the 70-year-old gentleman who has significant history of trauma at 20 years ago, actually having an on and off symptoms with it? Since then, he actually goes pain, gets swelling and clicking and unable to do the life activities.
However, the night's sleep is not disturbed. He has got two mechanical symptoms he's finding increasingly difficult to do his hobbies like golf. He's I would like to, since he hasn't had anything like anything done more than a simple painkillers. And he's otherwise medically only and diabetic, and he does take any medication for it. So my plan of management would be to start with the pain ladder approach, starting with increasing these painkillers.
Look at the physiotherapist to start my examination first to confirm my findings. I'll do some radiographs to confirm that whatever situation and the knee is, I suspect in my opinion it could be a post-traumatic osteoarthritis of the left knee. OK, when the time is up now. So in moving up to the examination part, ideally now during that exam, let's go through history now and then we'll see where we are now.
So just as of like critiquing of things, how do you think it's understand what you're seeing today is exactly like this patient, what you've been answered? He could have answered like an orthopedic surgeon, but he answered more or less like a patient. You agree to a certain degree. Yeah, Yeah. So it's not that he was giving you, giving you what probably a patient would answer in real life.
Yeah now, if you had to self critique yourself and is to take is important, what where do you think your strengths were? So give me your strength first. My strengths were to try to find out the systematically to starting from his age, then his problem and dealing with the problem and the pain and that. However, I did jump over to in the end, because I realized that I didn't ask about the important stuff hobbies I were in terms of.
I did. I think I did cover most of the important bits in history. It would have been a bit more organized, but but I went and I managed to actually get the most information. However, I did not go into the much detail in the accident and stuff like that because of the constraint of the time, because I wanted to go cover a lot of stuff.
But the symptoms was more towards the history was more suggesting towards the post-traumatic arthritis and injury, which is managing and clicking. So I think he has. So let me just tell you something. The number one, I think your strength is right and I don't know the other candidate, but your strength is and I think my other example is that you are very clear. All right.
So the way you talk is very confident and clear. Is that right for us? And I think sort of straightforward questions to get a straightforward answer and not Yes. So I think that's a very important skill. If you question the question you're asking, the patients are unclear or could have multiple answers, then it would be just wasting time. So I think it's a very good, useful skill and that's what you get through.
Most of the things within the five minutes, so for us, please agree with your own words, I want everyone to have ask targeted questions. So that's one, so let's keep that in mind. The second thing I have is that, yes, you had jumped into here and there, but let me, if you don't mind, let me just tell you the points you probably missed. OK and this is what everyone is going to write it down.
You can write it down. Yeah, let's all start by this. I would say the first thing when you have to. In the exam, please introduce yourself, as I would suggest, and but that do it, try not to say your first name, say Mr or Mr marshmallow, Mr Arnett. OK, just try to say that you don't have to say I am a candidate in the exam. I am this and that just say, is it all right?
If I ask you a few questions, that is short and straightforward. So happy with that. So you are taking the patient's permission, but not waiting for an answer and not giving the whole spiel. And one of the candidates, is it ok? Can I examine you? Give me pain? No play and don't say all that.
Happy with that? Yeah so I'm Mr marshmallow. Is it already asking you a few questions? Mr smith, I understand now in the exam, I have maybe two scenarios. You'll either be told that this patient got a problem with the left knee. You may be given a slip of paper saying that was saying that it's a problem with the left knee.
Or you would say to start with what the patient's problem. So if the patient has been told that the left knee, let's start off that I understand your problem. The left knee. How long has it been going on now for everyone? If someone says 20 years, please understand he's not waited 20 years to see you. I know NHS waiting list along, but no one will wait 20 years to see anyone.
All right. So try to come down and tell the patient to understand that. But what makes you come now? Has it become worse when so right to get the presenting symptoms? All right. So therefore the presenting symptom will be two years or one year. Try to get it off.
It is. That is the most best tip. I'll tell all of you. Please don't get into a 20 year history of something that will take five hours to finish. Happy to help with that. Yeah so you would have told Mr smith, thank you very much, but please understand why are you here now? Is it become worse now?
And then you say that then? He says it's more one year at one year, so you'll ask him, please tell me for one year when this pain started me or left me. Did it start? The only two options I did not with any trauma. Or did it start insidiously all over? Remember two words trauma or insidious? Now, if it is by itself, it's insidious.
If it's trauma for that one year, get the message whether a twisting injury or not play on that right? Yeah, Yeah. Now second is once you have the pain, you ask him the next question if for over one year has this been progressed, has it become better for some days or some days better? So in other words, you know, it's for one year, you know, the onset and the progression.
So what is this going? It's going to be happy with that, everyone. So one year, Mr smith, that you had this one year, it started by itself. Thank you. It's been there for one year. Is it better? Is it worse or are there some days or some days? Mm-hmm Now once you finish that.
It's go. If you're not going to just call someone else next after onset duration progress, go to the site of the site. OK OK. I'll ask you where the pain is, so this is where ahead. It was very important. You got that OK, which you didn't get because you were little involved in your history of the trauma.
You understand what I'm trying to say. Go ahead. Yeah OK. Carry on. So how are we going to ask him the site so that most people, if you ask the 80% of the local population in any country where the hip is, where do they go into? Most people thought going to the country area, right, if you ask the person you want the answer to be that he gets country area or as an orthopedic surgeon during the pain to be in the groin.
We orthopedic surgeons know the groin is the hip. Is that correct? Yes so therefore, I would suggest let's not be rude. You get pain in your hip. Ask the patient. You get pain in your groin, right? Correct? Yeah. Now I would say yes, therefore.
The next question therefore, says pain on the inside of the knee. Then carry on and saying thank you very much. But it's very important. You also get pain in your left groin. Now, suppose he says yes, then you have to clarify it with you. Get pain in your left groin, which goes down to your knee. Now you agree that is classic of hip pain, right?
Yeah, Yeah. So please ask him and say it in the same manner I've told you. So ask him that. So do you have any pain in the groin that goes down to your knee? Yes, say Yes. So then you get that information. Now Once again, I need to ask you about a. Back then, how are you going to differentiate back pain from hip pain, so ask him for the back pain.
A few is a week as examiners want to just know whether you're safe and whether you're going to list someone for a knee replacement or incorrectly some knee replacement. Actually, the problem is the hip you see, so we want to know whether you're safe. The minute we talk about site, the next question will be radiating pain. So these are the two questions.
Keep it simple. If this hip he says Yes in the groin, ask the question about the knee. If he says Yes for your back, you will say thank you very much. Do you have pain which goes down the back of your buttock through the back of your thigh below your knee? Feet below the knee associated with pins and needles to write it down.
These are very straightforward words which you don't have to study from any textbook, but this is classic or of back pain. So we've covered radiating. You agree? Yes One of the points we've covered sight. And radiation, and now we have to move on to someone else. We can go on telling you things. So what I would suggest is your first question, a very good respin.
So let's start. My thing is asking directly you have pain at NIPE with wakes you up, right? So it's very clear. Do you have pain at NIPE with axilo? Yeah now that is classical or very bad fenugreek. So that's one question. So here is which you didn't ask was walking distance, you know, to a certain degree, to the walking distance.
So when you are walking distance, it's best to ask walking distance in America. They ask it in blocks. But in the UK, we don't have blocks. So I would suggest everyone just ask that when you walk after, how many minutes does your knee pain stop you? Is that a simple phrase for everyone? Want to ask? I go to Tesco and stop.
You don't know where Tesco is. So tell me, Mr smith, how far can you walk in minutes before you are left making stops? You very clear he'll give you an answer. Suppose he says 10 minutes. Do you agree it's bad enough for a knee replacement? You agree, everyone. So we says 1 and 1/2 hours. The answer is no.
So one was nice to do was walking distance. What is tucked in is stair climbing. All right. So what does I have us? Ask him, do you have pavement going up and down stairs? Foot is pain when you get up from a sitting position. OK, so the best way to remember this is imagine an old man who is sitting in his chair at home watching TV that is called respin.
So being addressed, he gets up from the sitting position to go up to sleep that's been from getting up from a sitting position. Then he walks to his stairs in his house. What is that walking distance? Yeah then he goes up the stairs that is stair climbing and 50 goes to sleep, so the 5 points of severity are covered. If you remember old man. So these are mind repeating that, Mr. I think that's very useful reminder sort of way.
Yeah, thank you very much. So that's very, very important. I just I'm really quite very impressed. I just wanted to say we all underestimate the importance of history taking that first year, and we think it is easy. It's actually very, very it's easy if we know what to say. And we could very high mark to compensate for it is very easy. So many people I failed in the history part, and it's amazing.
Thank you so much. So the way I'm on this, I just to remind everyone it's similar and I have two aggravating factors, but I'm just putting in a simple manner. So the five points, I imagine an old man sitting in his chair watching TV, that's and he gets pain. That's resting. agree. That's a good question.
Second is he gets up from a sitting position to get up. So that's been so asked Mr smith, do you get pain when you get up from a sitting position? Right? third is he walks to his stairs. That's reminds your mind to ask about walking distance, right? Which is in time. You can ask it in length, but I prefer to ask it in time. Number four, you ask about, he goes up the stairs to go to his bedroom.
So that's your stair climbing thing, right? So you ask him the question. Mrs. smith, you get pain in your left knee when you climb up stairs. Yes, you get the answer very quickly 30 seconds. And number five, he goes to sleep and he gets pain. That's NIPE pain. All right. So for everyone.
After you finish pain, I would say, let's ask other symptoms in my mind. I'm talking about other symptoms. All right. So pain is your first thing, which we've discovered will be swelling. It's an easy question to get an answer. Does your knees swell up and always swollen? Or there's some days.
Some days was not time time. It really doesn't matter. Are they sometimes worse, some days better? The reason I say this is some people get a swelling in the knee and it may be a tumor, so it's more or less all the time. While on and off swelling is classical of what we normally see. So just ask the question is it swollen?
Answer is Yes all the time or some days where some days better? Right? the next question. I would suggest we ask is giving way. It's an easy question, and you asked it perfectly. Everyone can ask it another month, but keep the one phrase and all of you are preparing for the exam. Just stick to 1 phrase which you guys want to use.
I may use one phrase, but whatever it is, don't change. Don't on Tuesday and Wednesday ask in a different manner. That's what I'm trying to suggest to you. So I'll ask the question is Mr smith? Does it ever happen that you need collapses under you? That's all I ask. It is a very simple question does your knee collapse under? You can ask what you ask, which is absolutely fine. And then can someone tell me what other symptoms of giving way?
In a typical ACL knee in a young knot, Mr smith, he's 70. But if you have a 25% year old rugby, there's a difference between why I put this up is there's a difference between asking the question of giving way to a young rugby player compared to a 70-year-old man now in a younger. Tony Blair, Abdullah said it perfectly, the question you'd ask is Mr. Smith. Does it ever happen that if you're either walking or running and you suddenly change direction or pivot pivot?
Most rugby players know the word pivot. Will your knees collapse under you? All right. So that's classical of the ACL. The second history of the law, which I was trying to get, is this injury. Rugby players find that going down stairs, then it collapses. Yes, they're always holding on to benefits. However, how they are working on physios use muscles, but they feel they need to do questions for the young person.
But the older person, it's just the knee collapse under you. Mainly they have it when they get up from a sitting position. So, so the next question is looking so for looking. I think? Sriram asked. I ask the question very clearly, does it ever happen that you need get stuck and you cannot straighten it completely with five words? There's nothing more to it unless you know it for us or anyone else has another way of asking.
I just sometimes I ask, does you need luck? And they seem to understand that sometimes we were stuck in lock. The reason I agree most of them, but sometimes patients get I don't like to be them to confuse docking and stiffness. So, you know, that's where I feel. Sometimes I egawa because they dismiss and I don't care with the assistive, you know, I don't operate on anyway.
They'll last. Patients won't be anything for a certain degree. I think. I think it's likely that I have picked that from you because it's exactly the same sentence that I would say I would ask, does your knee get stuck in one position and you can't move it? Move it? Yeah that's the third symptom.
And now there's only one symptom left which people forget. And I ask the question has it ever happened that your knees become more deformed? In other words, Mr smith, have you become more not need or bowlegged? All right. So that's your fifth symptom. Clear? very simple. Ask that.
Now, once we finish these five points, which is pain, but we agree we subdivided into many points, which is the onset, the duration, the progress in the site and incite anger. If we remember, we divided into radiating pain for hip and knee hip and back then we moved on to severity, which were five questions, and we moved on to other symptoms which were really knocking, swelling, giving way, locking and deformity.
Now is the time when I ask, please tell me, you know, Mr smith, you told me about your history, so I put my head in the past. Ministry all right, so in the boss ministry, I ask all these things, like 20 years ago, what happened to you? So he'd say Yes if any of you add up all of a motorbike. Now, as long as we've asked the main thing you can carry on about his year history, you see, and you're asked about in your personal history, have you had any operations to your knee?
You say Yes or no? Have you had any painkillers for your knee and you use any stick or support? The only three questions I want, right? I don't want anything else. So have you had any operations? Have you had any physiotherapy? Have you had any painkillers and you use a stick? Yes, that's what I want to know from treatment taken for his knee.
The lost history includes any trauma, and in that trauma I want to ask specifically ask is very important for me in your past history of your knee. Have you had any problems your knee in child, knee or hip in childhood or infancy? Have you had any fractures of your pelvic femur or tibia? And have you had any knee operations in the past? You say Yes or you say no? That's all.
Now we move on to what would someone else if you don't want? OK Yeah. Many major problems and someone who has no medical problem will give a list of a huge amount of medical problems. That's real life. You want that answer or do you want to know as an orthopedic surgeon what is important for you? I suggest that you finish your history of the past history before you go to past medical history.
Just clarify in my mind what I call other joint history, because you will have a patient with a rheumatoid arthritis as an intermediate case that Mason would have had a left hip, done right, hip, done elbow and right shoulder. And you agree. Yeah is a good time to introduce what I call in my head. Other joint history. Then your other joint history?
I'll ask. Now, tell me saying that you were talking about your left hip. Which hip have you had replaced using my right and your shoulder? Is that correct? You say right shoulder? Yeah so you get information about other joints. Happy with that.
Yeah, Yeah. That needs leads you nicely to medical history. Now I would suggest in your mind for preparation, you have to have some things with your mind that you're moving from one to the other, not to the examiner, but to yourself. And I would suggest, is a good time to ask history of Allen. So once you finish the knee and joints, let's not mind from today.
Always remember that before we go to anything like medical and social history will ask, are you have any allergies? Happy with that, right? So this is what if you don't know this about us? So you're going to ask that you have any allergy? He says Yes or no. And after this, when I ask my medical history, I ask it very clearly like this that ask him, do you have any diabetes?
Yes or no? Why am I asking diabetes? Because it's important for the anesthetic point of view, as well as for anesthetics? People know. So why is it important for me and you? What is the real crux of diabetes? Yeah, because it's the chance of infection is high. Fantastic so it's our counseling.
All right. So what I'm trying to get it for you is that we are not here to judge anesthetic fitness. I'm here to counsel you and tell you, look, you are higher risk or lower risk. So that's all I ask for medical history. So let's ask for diabetes. You have to ask the next question ask, do you have any problems with blood pressure?
Yes or no? If they say Yes and most people no hypertension. Why am I asking that? Because blood pressure is one of the important things. If you have unstable blood hypertension or if you have fulminating, you really have. You are not going to be a candidate for elective surgery, right? So that's the question I ask you, ok?
Number three I ask for. Do you have any? Do you have any? Have you had any recent heart attack or stroke? Why is that important? Because he might be on some blood thinners. More than that, elective surgery cannot be done with recent MI or stroke. You remember, this is what we want to look at.
So when we have a grid has, as we all know, so. So they are contraindications to joint replacement surgery. And one of the contraindications to elective surgery is recent MI or stroke. You agree? Yeah so let's ask it directly. So you ask them about blood pressure. You ask for diabetes. Have you had any recent heart attack or stroke?
He says no. Then you go on to I ask a direct question, do you have any breath? So I want you to stop you from walking? Is it your knee pain or your breathlessness? All right, because as orthopedic surgeons, I don't care whether he's taking this for better or not. All I want to know if his breathlessness stops him before his knee pain, do you agree?
Will not offer a knee replacement surgery? You agree. Yeah Yeah. If his knee pain stops in before breathlessness, of course you're all for it. You tell him it's high risk, but you're off it. Is that correct? Yeah, that's correct. So let's just ask this question.
That's the same question to my angina. So you ask Mr smith, do you have any chest pain? He says, yes, you're going to ask him, what stops you, Mr smith? Does your chest pain stop you or your left knee been stopped? Yeah, Yeah. Yeah so that's my that's my seven question on history, on medical. Then I move on to just ask a very straightforward question onto drugs, which affect me.
I ask him, do you take any blood thinners? Why is that important? Because it affects me. Yeah, you take any drugs like steroids, because it affects me. Because his risk is higher. You take any drugs for inflammation like rheumatoid arthritis. Don't ask him, do you take any tricks it?
You don't know what you're talking about, just say you take any drugs which you take for any inflammation like rheumatoid arthritis. That's your third question. Are there any other drugs which you think need to be asked, or is that mainly they'll be axilo Latinos medications, steroids, steroids among medical medication, you know, they can take anything. So let's say steroids is important.
Anti-inflammatory drugs like me to track some important and blood thinners important, right? Yeah and then I ask him, have you had any surgery, which has left you with any weak wound or sore area, right? You agree is an important question. Yeah, that's important. And that's all I ask in medical history. Then if he offers for thyroid and things, then I get it.
You know, you can't ask everyone, everything. And the last thing I end with socialist or socialist streak, I ask him, you said you were a plumber, you still work or do you have people to work for you? All right. So that's one. And number two, you smoke. Your smoking is important. Yes high risk.
And number three, are there any activities you have stopped doing only because your left knee pain, because people may stop playing golf because the golf partners have died, but doesn't mean you have to do a knee replacement for them? Yeah, you do it because they get pain in the left knee and that stops them. So they're very direct question here. And that's how I end.
So you can co-morbidities. Leading questions, please, Mr. MacFarlane said, if you start opening questions, you'll end up nowhere and you waste the whole five minutes leading questions, focusing on three points. Previous Joint Surgery ask the patient have you had previous joint surgery? Have you had any complications? And that he would tell you the wound infection or so forth?
Thank you very much. That's a good point. I have never thought of it, but I want to say it. I want to. I want to make sure I say it. Thank you. Very good. I understand this. Previous Joint Surgery.
Any contraindications to operation, recent MRI or stroke. And any comorbidities that affect the outcome. So these three things, yeah, joint surgery, comorbidities that would be contraindications or comorbidities that affect the outcome. You don't want that one last question is there anything else you want to tell me? They might tell you, Oh yes, I had the TB when I was three years old.
They might tell you things that you never thought about. And they might say, well, you know, you never asked me, you know, you just have to ask them. And they were some volunteer that information. So it's worthwhile. There could be the question that makes you be what you once said. So what I would say, then make sure we end with Sean's last statement.
I will make it clear that I do it next time, and we will say that summarize for the patient. And this is what one is telling you is exactly what I'm going to tell you later on is the most important person in the room is who is the patient? All right, it's not the examiners, it's the patient, and you have to summarize to the patient. So that's a nice way of summarizing it. And then let's all ask the question have I missed anything fantastic, ron?
Thanks for that. So that leaves me with that. All right. We're on history. Thank you. So let's one good point, and that's what I want to tell you. Let us most likely and because I've given the examiner 25 years ago, people who them earlier will testify that for short cases that we want, most likely the patient is prepared for you and you are all right for short cases.
There'll be no shorts or a skirt, you know, ready for you on a bed, right? For an intermediate case, it's very likely the patient will be sitting in a shirt and trousers, right? Very likely. Hence, I want you now to ask him, you're not going to do it on screen. Don't worry, he's not going to strip, but that's what I think that is.
But imagine what are you going to tell him him if I can go out some underwear? So can you take the toggle off for me, please? Yes OK. No can you please stand up and I'm looking from the front on inspection looking for 1 minute. I know you are going to, but when are you going to inspect these shoes or have you forgotten truthfully?
After the gate, I would do the inspection. That's what I know. And looking from the front, side and back, you see shoes, the shoes. All right. You agree to that as well. Yeah so everyone, so what I would suggest is just memorize it, practice on your wives of family members. Mr smith, you mind removing your trousers and your socks and shoes and please pass me your shoes.
And do you have a stick? You know, look around like that. You have a stick. Now you make the statement. You never forget to stick and walk. You never forget shoes, and you'll never forget to make him undress. You're happy with that. Yeah so please tell him that again.
I want the same statement. What I said to Mr smith, do you mind? Do you mind taking your trousers off in your shoes and your socks off as well? I'm looking for a stick. And ask him, not looking? Just ask Mr smith, you have a stick on a stick. You know, on as if you're asking him who is the most important person, the patient focus it on him.
So ask you, Mr hair, do you have a. Mr smith, take your trousers off and also your socks and shoes, please, and do you use any stick? And then say, please pass me your shoes. They forced me and I look, why? So it's while he's undressing. Happy enough?
Yeah and next, we'll do. What do you want to do next in your big headache? You want to do gait or inspection the front from describe shoes for the exam and get away with a lower limb for all the excitement. The way you do this? Imagine now your patient is undressing, right, so you can't do anything else. So it's a good time to see shoes you agree on.
What? Yeah. So you pick up the shoes. Watch what I'm doing now. What am I looking for? Now look at it. Can you see that there? Yes, we can see which can't see the shoes. Yeah so what am I pointing to?
So the first thing I say, the more here is the green. That's the correct word. Yeah then I put my hand here, and I put it inside. What am I looking for with my hand in here? It's for an internal. Hillary's happy. Yeah then I put my hand inside the medial arch, and the word I'm going to use is there is no medial arch support.
Yeah so why am I saying this? We all agree that passing the exam is not speaking English correctly. It's speaking the language of Watergate. So are these direct words or other insoles. So there's no external heel support. There's no heel, there's no medial support. When I turn the shoe over this and I say there's no due where I turn on one side compared to the other, I'd be happy.
Good phrase. And there is no stretch suggestive of a bunion or a bunny in it. Right? so can you repeat that? So there's no start again. There is no external that there's no internal injuries and there is no asymmetrical way of looking from the back. There's no bunion.
No, I don't know that there's no stretch suggestive of a bunion or a bunny in it. Yeah OK, now you don't have to say all this, but at least you can make your effort of actually looking at it correctly. All right. But what I don't want you to do is don't just pick up the sheet as if you're halfway through this. Look at it and then throw it away.
We're looking at you. Yeah, Yeah. The point I'm going to make for you, for the clinical exams, this is not marks. What we do is we are going to watch every move you make is correct and you can't say something and do something and say something else. All right. So if you're looking at shoes, don't look at the front of your shoe and say there's no asymmetrical way.
How can you look at the asymmetry from the front? You agree what I'm trying to say. Yeah, OK. So do it all that. Yeah, good. So that's where we are, for sure. And then I progress to inspection and clinical findings, which I think we can be over one. You can do it.
I just wanted to give a flag off something. And if it works well, we can do it like we discussed last time. I think it worked very well. I just ignored the examiners. Really ignore it, like what I'm doing in my clinic. And I got this from examining the students because as an examiner. When I see a student coming to me, just looking at me and doing like this and.
My first impression that this country is not confident, but the candidate who comes listen to me say after I tell him then. Even been looking at me and just concentrating with the patient, I would really, really respect this candidate and this is what I did in my exam. The other thing I I, I started to work on establishing a rapport with the patient quickly, and this is exactly what Sean said more or less I start to make like we are friends.
Hi, how are you today? I was just a quick question in two seconds. Was this your new was usually OK today to come over here to the hospital? And I'm sure the examiner and the patient would just both get relaxed because you are now a professional consultant, you are. You are talking to your patient and taking care, even how and what is comfortable now.
Fantastic very correct. I can't. I can't agree more. Yeah so and make jokes. If you if there is something about jokes, make jokes. No problem, ok? If you are examining like something and will be ticklish, oh, be careful. This will be ticklish.
And then crack a joke. No problem. At the end of the day, what I've noticed that it is, it is not very formal. And even if you miss something but you establish this report and you made the patient, that is the examiner will be at ease. And then you will reach quickly to the answers. He will not play with you much and the patient will help you.
So these are my simple tips. Establish, report, ignore the examiner while you are talking to just concentrate as if you are in the clinic and actually think about the examiner as a medical student and you are showing him how you are doing this. That's it. Thank you. Thank you.
To build on what Sam said to a couple of points where you guys can get into trouble without realizing you got into trouble, your examiners will ask the patient what they think of you at the end of the exam. If you have a patient, if you think something is going to be painful to them, turn around, turn around to your examiners and say this part of the exam will be very painful for the patient or will be painful for the patient.
I do not wish to inflict pain on this patient in this scenario. In in this setting, they will say no, go ahead and then it's on them, but you take care. If they wince, you stop. Just say I'm not comfortable. If they usually say no move on, leave that step. But they recognize the fact that you said that is painful. For example, a patient who potentially has CRP. Yes, I said this might hurt if I touch you.
Is it OK to touch you? I didn't actually touch the patient until I checked. They have pain there, and then I rub the leg and they say, what are you looking for? I'm looking for crops. They like the fact that I ask permission first before I did it. Ok? absolutely.
These are very, very important thing. They are not simple tool. They are essential and they are passed on. For some people, that's what some people don't know why they fail the exam. They said, oh, I only had the case of knee arthritis, but we see every day in clinic and I ask all the questions and they surprise why they fail. All these points are more important to the examiner because we all know that the patient has knee arthritis from the minute they get into the room.
But all these points are for safety. They're looking for a safe surgeon who will respect the patient dignity of the patient and is safe. Also safe means they will offer the write operation for the right condition. So yeah, these are essential things. So Virgil, I. So the takeaway message with all of us is that from today onwards, there is no way that the examiner is important.
And that's a fundamental difference between trainees and non to a certain degree that we really worry too much that the examiners will. There's a problem with. We are focused too much on the examiners and all of us have said that you will focus from today onwards only on the patient. That's your main rapport to have with. And I also like a point that when the unrest, I always say, please have a seat or you look after them.
Another point for the history you are. Now take a history. If your standing and the patient is sitting right, ask for a chair. Tell the examiner, please, I need a chair. You pay 2500 pounds for the exam. The least you can get is a chair. All right, so ask for a chair and sit down. So no standing.
I want. Husam says you absorb everything, change your maybe some of us need to change the behavior even. Yeah, it takes time. It's not easy to adapt. So that's brilliant. Thank you very much. Excellent I think if everyone is happy, we will end this session.
We could go forever and think tomorrow morning about it, have to end at some point. So thank you very much, Mr mvala. Thank you. Thank you for your input here. You're making a huge difference to everyone who is attending. Thank you, sir. Thank you. And I'm sure we all appreciate it, to be honest.
And Thanks again to Sean, who came straight from work and has some set of flies, those joining us from his international candidates. He's joining us from Saudi Arabia, where he's his pastor. He's now supporting us and. The attack was left at the moment, but there also was here to start with next week we'll be watching and hopefully we'll be able to offer you more practice again next week.
Thank you, everyone, and good NIPE. Thank you, Allen. Thanks again for bye bye. Bye bye.
Segment:0 .
If you don't mind me, me and Zubin will be there for us. The examiner and my other colleagues will also be the co examiners. So I mean, yeah, imagine this is imagine this is a real exam. You know, it's difficult within the constraints we have. But imagine you are actually entering a cubicle. Yeah, sure, you are in the first case exam. Yes yeah, that's it. And to be taken through to examiners there, someone taking you through the examiner.
Mr and mavela is your examiner here and Zubin is the patient. Balasaheb will come exam I'm your examiner, Mr. Morrison. You have a patient at the moment. We're going to take you to see who is having a problem with his knee. So can you? Yeah can you please come and ask him a few questions? Find out what's going on with him. You have five minutes.
Hello, I'm Mr. Francisco Examiner. This is Mr. Smith. Please carry on. Oh, hi, my name is Saeed. Thanks for letting me examine you. Tell me. How old are you if you don't mind me asking? How old I am, I'm 70, 70 years old, ok? And what seems to be a problem, how can I help you?
Having left me? How long has it been going on for? Thank you. It's for 20 years now, 20 years. OK how it all started. The last 20 years, like it started slowly and slowly, I can hardly hear you. For the last 20 years, I'm having this pain. Yeah so then you left me has got a pain.
Yeah, Yeah. Do you have any full? Yes, I had to fill in. OK when was this? I was driving a motorbike, so like, I just kind of had to wait. So you fell from the motorbike 20 years ago? Not recently. No right?
Was anything done about that? Sorry about that. Yeah I had some painkillers and physiotherapy. That's right. Did you have any fracture was diagnosed at the time? No, not really. Not a fracture. All right. OK any other soft tissue injuries was diagnosed at the time.
Yeah, it was like the doctors told me, like some sort of injury, but I carried on with it, right? So you never say seek any medical attention for it. I went to the doctor, he gave me medicines, I applied some ice and that's it. So did you manage since then well, or is it still a problem? Since then, the beginning, it was less but slowly I'm feeling the pain, right? So your seven year old, you had an injury from the motorbike 20 years ago when you in your age of 50.
And then so did you have a pain? Your pain got better in the meantime. How? you can see that it got better. Yeah, it was like better or it was better was like this kind of thing, OK, so on and off pain, was it actually? Are you off your knee? Give it all.
Yeah, sometimes it gives way a bell. Going downstairs, going upstairs. Yeah well, going downstairs, it gives me. All right. OK, so how do you manage normally, stairs and everything? Recently, I'm feeling more pain. OK, well, climbing down the stairs does your knee. Click the.
It does. Yeah OK. Anything else being done about it at all? Nothing I'm just using a stick now. OK to managing with it. Right, and in terms of the gasoline at all. Yes, intelectual, yes, right, OK. And when you do any tea, what does it stop you doing it? Sorry what stopped you doing that accountability?
Will you be affected? I am not able to play golf. I'm not able to, you know, go to the markets for doing my usual stuff. OK you take any medication for it at all. Yes, I take painkillers on off. OK, any other medical problem you suffer from? Yes, I have like hypertension and diabetes. Diabetes as well in hypertension.
And you take medication for it. Any blood thinners at all? Not really anything allergic to any other medical problem. I need to know. No what are your expectations and what do you want? Is to be done then about that? But I just want to get you to the pain and spend my life pain free. Does this does this pain disturb your sleep in the NIPE at all?
Not anymore. So you are managing with painkillers without disturbing your night's sleep and get the pain at NIPE. It's only like when I walk, then only I get the pain right? And does it? I mean, your hobbies wise, do you work? Do you still work or are you tired? Well, right now? No, I used to work as a plumber, but I left my job because of the pain, because of failure.
OK, any hobbies you still do, which you can cannot manage anymore. I love playing golf, which I'm not able to play now. Right OK, so OK, thank you very much. So let me see, do I have a shot of the 70-year-old gentleman who has significant history of trauma at 20 years ago, actually having an on and off symptoms with it? Since then, he actually goes pain, gets swelling and clicking and unable to do the life activities.
However, the night's sleep is not disturbed. He has got two mechanical symptoms he's finding increasingly difficult to do his hobbies like golf. He's I would like to, since he hasn't had anything like anything done more than a simple painkillers. And he's otherwise medically only and diabetic, and he does take any medication for it. So my plan of management would be to start with the pain ladder approach, starting with increasing these painkillers.
Look at the physiotherapist to start my examination first to confirm my findings. I'll do some radiographs to confirm that whatever situation and the knee is, I suspect in my opinion it could be a post-traumatic osteoarthritis of the left knee. OK, when the time is up now. So in moving up to the examination part, ideally now during that exam, let's go through history now and then we'll see where we are now.
So just as of like critiquing of things, how do you think it's understand what you're seeing today is exactly like this patient, what you've been answered? He could have answered like an orthopedic surgeon, but he answered more or less like a patient. You agree to a certain degree. Yeah, Yeah. So it's not that he was giving you, giving you what probably a patient would answer in real life.
Yeah now, if you had to self critique yourself and is to take is important, what where do you think your strengths were? So give me your strength first. My strengths were to try to find out the systematically to starting from his age, then his problem and dealing with the problem and the pain and that. However, I did jump over to in the end, because I realized that I didn't ask about the important stuff hobbies I were in terms of.
I did. I think I did cover most of the important bits in history. It would have been a bit more organized, but but I went and I managed to actually get the most information. However, I did not go into the much detail in the accident and stuff like that because of the constraint of the time, because I wanted to go cover a lot of stuff.
But the symptoms was more towards the history was more suggesting towards the post-traumatic arthritis and injury, which is managing and clicking. So I think he has. So let me just tell you something. The number one, I think your strength is right and I don't know the other candidate, but your strength is and I think my other example is that you are very clear. All right.
So the way you talk is very confident and clear. Is that right for us? And I think sort of straightforward questions to get a straightforward answer and not Yes. So I think that's a very important skill. If you question the question you're asking, the patients are unclear or could have multiple answers, then it would be just wasting time. So I think it's a very good, useful skill and that's what you get through.
Most of the things within the five minutes, so for us, please agree with your own words, I want everyone to have ask targeted questions. So that's one, so let's keep that in mind. The second thing I have is that, yes, you had jumped into here and there, but let me, if you don't mind, let me just tell you the points you probably missed. OK and this is what everyone is going to write it down.
You can write it down. Yeah, let's all start by this. I would say the first thing when you have to. In the exam, please introduce yourself, as I would suggest, and but that do it, try not to say your first name, say Mr or Mr marshmallow, Mr Arnett. OK, just try to say that you don't have to say I am a candidate in the exam. I am this and that just say, is it all right?
If I ask you a few questions, that is short and straightforward. So happy with that. So you are taking the patient's permission, but not waiting for an answer and not giving the whole spiel. And one of the candidates, is it ok? Can I examine you? Give me pain? No play and don't say all that.
Happy with that? Yeah so I'm Mr marshmallow. Is it already asking you a few questions? Mr smith, I understand now in the exam, I have maybe two scenarios. You'll either be told that this patient got a problem with the left knee. You may be given a slip of paper saying that was saying that it's a problem with the left knee.
Or you would say to start with what the patient's problem. So if the patient has been told that the left knee, let's start off that I understand your problem. The left knee. How long has it been going on now for everyone? If someone says 20 years, please understand he's not waited 20 years to see you. I know NHS waiting list along, but no one will wait 20 years to see anyone.
All right. So try to come down and tell the patient to understand that. But what makes you come now? Has it become worse when so right to get the presenting symptoms? All right. So therefore the presenting symptom will be two years or one year. Try to get it off.
It is. That is the most best tip. I'll tell all of you. Please don't get into a 20 year history of something that will take five hours to finish. Happy to help with that. Yeah so you would have told Mr smith, thank you very much, but please understand why are you here now? Is it become worse now?
And then you say that then? He says it's more one year at one year, so you'll ask him, please tell me for one year when this pain started me or left me. Did it start? The only two options I did not with any trauma. Or did it start insidiously all over? Remember two words trauma or insidious? Now, if it is by itself, it's insidious.
If it's trauma for that one year, get the message whether a twisting injury or not play on that right? Yeah, Yeah. Now second is once you have the pain, you ask him the next question if for over one year has this been progressed, has it become better for some days or some days better? So in other words, you know, it's for one year, you know, the onset and the progression.
So what is this going? It's going to be happy with that, everyone. So one year, Mr smith, that you had this one year, it started by itself. Thank you. It's been there for one year. Is it better? Is it worse or are there some days or some days? Mm-hmm Now once you finish that.
It's go. If you're not going to just call someone else next after onset duration progress, go to the site of the site. OK OK. I'll ask you where the pain is, so this is where ahead. It was very important. You got that OK, which you didn't get because you were little involved in your history of the trauma.
You understand what I'm trying to say. Go ahead. Yeah OK. Carry on. So how are we going to ask him the site so that most people, if you ask the 80% of the local population in any country where the hip is, where do they go into? Most people thought going to the country area, right, if you ask the person you want the answer to be that he gets country area or as an orthopedic surgeon during the pain to be in the groin.
We orthopedic surgeons know the groin is the hip. Is that correct? Yes so therefore, I would suggest let's not be rude. You get pain in your hip. Ask the patient. You get pain in your groin, right? Correct? Yeah. Now I would say yes, therefore.
The next question therefore, says pain on the inside of the knee. Then carry on and saying thank you very much. But it's very important. You also get pain in your left groin. Now, suppose he says yes, then you have to clarify it with you. Get pain in your left groin, which goes down to your knee. Now you agree that is classic of hip pain, right?
Yeah, Yeah. So please ask him and say it in the same manner I've told you. So ask him that. So do you have any pain in the groin that goes down to your knee? Yes, say Yes. So then you get that information. Now Once again, I need to ask you about a. Back then, how are you going to differentiate back pain from hip pain, so ask him for the back pain.
A few is a week as examiners want to just know whether you're safe and whether you're going to list someone for a knee replacement or incorrectly some knee replacement. Actually, the problem is the hip you see, so we want to know whether you're safe. The minute we talk about site, the next question will be radiating pain. So these are the two questions.
Keep it simple. If this hip he says Yes in the groin, ask the question about the knee. If he says Yes for your back, you will say thank you very much. Do you have pain which goes down the back of your buttock through the back of your thigh below your knee? Feet below the knee associated with pins and needles to write it down.
These are very straightforward words which you don't have to study from any textbook, but this is classic or of back pain. So we've covered radiating. You agree? Yes One of the points we've covered sight. And radiation, and now we have to move on to someone else. We can go on telling you things. So what I would suggest is your first question, a very good respin.
So let's start. My thing is asking directly you have pain at NIPE with wakes you up, right? So it's very clear. Do you have pain at NIPE with axilo? Yeah now that is classical or very bad fenugreek. So that's one question. So here is which you didn't ask was walking distance, you know, to a certain degree, to the walking distance.
So when you are walking distance, it's best to ask walking distance in America. They ask it in blocks. But in the UK, we don't have blocks. So I would suggest everyone just ask that when you walk after, how many minutes does your knee pain stop you? Is that a simple phrase for everyone? Want to ask? I go to Tesco and stop.
You don't know where Tesco is. So tell me, Mr smith, how far can you walk in minutes before you are left making stops? You very clear he'll give you an answer. Suppose he says 10 minutes. Do you agree it's bad enough for a knee replacement? You agree, everyone. So we says 1 and 1/2 hours. The answer is no.
So one was nice to do was walking distance. What is tucked in is stair climbing. All right. So what does I have us? Ask him, do you have pavement going up and down stairs? Foot is pain when you get up from a sitting position. OK, so the best way to remember this is imagine an old man who is sitting in his chair at home watching TV that is called respin.
So being addressed, he gets up from the sitting position to go up to sleep that's been from getting up from a sitting position. Then he walks to his stairs in his house. What is that walking distance? Yeah then he goes up the stairs that is stair climbing and 50 goes to sleep, so the 5 points of severity are covered. If you remember old man. So these are mind repeating that, Mr. I think that's very useful reminder sort of way.
Yeah, thank you very much. So that's very, very important. I just I'm really quite very impressed. I just wanted to say we all underestimate the importance of history taking that first year, and we think it is easy. It's actually very, very it's easy if we know what to say. And we could very high mark to compensate for it is very easy. So many people I failed in the history part, and it's amazing.
Thank you so much. So the way I'm on this, I just to remind everyone it's similar and I have two aggravating factors, but I'm just putting in a simple manner. So the five points, I imagine an old man sitting in his chair watching TV, that's and he gets pain. That's resting. agree. That's a good question.
Second is he gets up from a sitting position to get up. So that's been so asked Mr smith, do you get pain when you get up from a sitting position? Right? third is he walks to his stairs. That's reminds your mind to ask about walking distance, right? Which is in time. You can ask it in length, but I prefer to ask it in time. Number four, you ask about, he goes up the stairs to go to his bedroom.
So that's your stair climbing thing, right? So you ask him the question. Mrs. smith, you get pain in your left knee when you climb up stairs. Yes, you get the answer very quickly 30 seconds. And number five, he goes to sleep and he gets pain. That's NIPE pain. All right. So for everyone.
After you finish pain, I would say, let's ask other symptoms in my mind. I'm talking about other symptoms. All right. So pain is your first thing, which we've discovered will be swelling. It's an easy question to get an answer. Does your knees swell up and always swollen? Or there's some days.
Some days was not time time. It really doesn't matter. Are they sometimes worse, some days better? The reason I say this is some people get a swelling in the knee and it may be a tumor, so it's more or less all the time. While on and off swelling is classical of what we normally see. So just ask the question is it swollen?
Answer is Yes all the time or some days where some days better? Right? the next question. I would suggest we ask is giving way. It's an easy question, and you asked it perfectly. Everyone can ask it another month, but keep the one phrase and all of you are preparing for the exam. Just stick to 1 phrase which you guys want to use.
I may use one phrase, but whatever it is, don't change. Don't on Tuesday and Wednesday ask in a different manner. That's what I'm trying to suggest to you. So I'll ask the question is Mr smith? Does it ever happen that you need collapses under you? That's all I ask. It is a very simple question does your knee collapse under? You can ask what you ask, which is absolutely fine. And then can someone tell me what other symptoms of giving way?
In a typical ACL knee in a young knot, Mr smith, he's 70. But if you have a 25% year old rugby, there's a difference between why I put this up is there's a difference between asking the question of giving way to a young rugby player compared to a 70-year-old man now in a younger. Tony Blair, Abdullah said it perfectly, the question you'd ask is Mr. Smith. Does it ever happen that if you're either walking or running and you suddenly change direction or pivot pivot?
Most rugby players know the word pivot. Will your knees collapse under you? All right. So that's classical of the ACL. The second history of the law, which I was trying to get, is this injury. Rugby players find that going down stairs, then it collapses. Yes, they're always holding on to benefits. However, how they are working on physios use muscles, but they feel they need to do questions for the young person.
But the older person, it's just the knee collapse under you. Mainly they have it when they get up from a sitting position. So, so the next question is looking so for looking. I think? Sriram asked. I ask the question very clearly, does it ever happen that you need get stuck and you cannot straighten it completely with five words? There's nothing more to it unless you know it for us or anyone else has another way of asking.
I just sometimes I ask, does you need luck? And they seem to understand that sometimes we were stuck in lock. The reason I agree most of them, but sometimes patients get I don't like to be them to confuse docking and stiffness. So, you know, that's where I feel. Sometimes I egawa because they dismiss and I don't care with the assistive, you know, I don't operate on anyway.
They'll last. Patients won't be anything for a certain degree. I think. I think it's likely that I have picked that from you because it's exactly the same sentence that I would say I would ask, does your knee get stuck in one position and you can't move it? Move it? Yeah that's the third symptom.
And now there's only one symptom left which people forget. And I ask the question has it ever happened that your knees become more deformed? In other words, Mr smith, have you become more not need or bowlegged? All right. So that's your fifth symptom. Clear? very simple. Ask that.
Now, once we finish these five points, which is pain, but we agree we subdivided into many points, which is the onset, the duration, the progress in the site and incite anger. If we remember, we divided into radiating pain for hip and knee hip and back then we moved on to severity, which were five questions, and we moved on to other symptoms which were really knocking, swelling, giving way, locking and deformity.
Now is the time when I ask, please tell me, you know, Mr smith, you told me about your history, so I put my head in the past. Ministry all right, so in the boss ministry, I ask all these things, like 20 years ago, what happened to you? So he'd say Yes if any of you add up all of a motorbike. Now, as long as we've asked the main thing you can carry on about his year history, you see, and you're asked about in your personal history, have you had any operations to your knee?
You say Yes or no? Have you had any painkillers for your knee and you use any stick or support? The only three questions I want, right? I don't want anything else. So have you had any operations? Have you had any physiotherapy? Have you had any painkillers and you use a stick? Yes, that's what I want to know from treatment taken for his knee.
The lost history includes any trauma, and in that trauma I want to ask specifically ask is very important for me in your past history of your knee. Have you had any problems your knee in child, knee or hip in childhood or infancy? Have you had any fractures of your pelvic femur or tibia? And have you had any knee operations in the past? You say Yes or you say no? That's all.
Now we move on to what would someone else if you don't want? OK Yeah. Many major problems and someone who has no medical problem will give a list of a huge amount of medical problems. That's real life. You want that answer or do you want to know as an orthopedic surgeon what is important for you? I suggest that you finish your history of the past history before you go to past medical history.
Just clarify in my mind what I call other joint history, because you will have a patient with a rheumatoid arthritis as an intermediate case that Mason would have had a left hip, done right, hip, done elbow and right shoulder. And you agree. Yeah is a good time to introduce what I call in my head. Other joint history. Then your other joint history?
I'll ask. Now, tell me saying that you were talking about your left hip. Which hip have you had replaced using my right and your shoulder? Is that correct? You say right shoulder? Yeah so you get information about other joints. Happy with that.
Yeah, Yeah. That needs leads you nicely to medical history. Now I would suggest in your mind for preparation, you have to have some things with your mind that you're moving from one to the other, not to the examiner, but to yourself. And I would suggest, is a good time to ask history of Allen. So once you finish the knee and joints, let's not mind from today.
Always remember that before we go to anything like medical and social history will ask, are you have any allergies? Happy with that, right? So this is what if you don't know this about us? So you're going to ask that you have any allergy? He says Yes or no. And after this, when I ask my medical history, I ask it very clearly like this that ask him, do you have any diabetes?
Yes or no? Why am I asking diabetes? Because it's important for the anesthetic point of view, as well as for anesthetics? People know. So why is it important for me and you? What is the real crux of diabetes? Yeah, because it's the chance of infection is high. Fantastic so it's our counseling.
All right. So what I'm trying to get it for you is that we are not here to judge anesthetic fitness. I'm here to counsel you and tell you, look, you are higher risk or lower risk. So that's all I ask for medical history. So let's ask for diabetes. You have to ask the next question ask, do you have any problems with blood pressure?
Yes or no? If they say Yes and most people no hypertension. Why am I asking that? Because blood pressure is one of the important things. If you have unstable blood hypertension or if you have fulminating, you really have. You are not going to be a candidate for elective surgery, right? So that's the question I ask you, ok?
Number three I ask for. Do you have any? Do you have any? Have you had any recent heart attack or stroke? Why is that important? Because he might be on some blood thinners. More than that, elective surgery cannot be done with recent MI or stroke. You remember, this is what we want to look at.
So when we have a grid has, as we all know, so. So they are contraindications to joint replacement surgery. And one of the contraindications to elective surgery is recent MI or stroke. You agree? Yeah so let's ask it directly. So you ask them about blood pressure. You ask for diabetes. Have you had any recent heart attack or stroke?
He says no. Then you go on to I ask a direct question, do you have any breath? So I want you to stop you from walking? Is it your knee pain or your breathlessness? All right, because as orthopedic surgeons, I don't care whether he's taking this for better or not. All I want to know if his breathlessness stops him before his knee pain, do you agree?
Will not offer a knee replacement surgery? You agree. Yeah Yeah. If his knee pain stops in before breathlessness, of course you're all for it. You tell him it's high risk, but you're off it. Is that correct? Yeah, that's correct. So let's just ask this question.
That's the same question to my angina. So you ask Mr smith, do you have any chest pain? He says, yes, you're going to ask him, what stops you, Mr smith? Does your chest pain stop you or your left knee been stopped? Yeah, Yeah. Yeah so that's my that's my seven question on history, on medical. Then I move on to just ask a very straightforward question onto drugs, which affect me.
I ask him, do you take any blood thinners? Why is that important? Because it affects me. Yeah, you take any drugs like steroids, because it affects me. Because his risk is higher. You take any drugs for inflammation like rheumatoid arthritis. Don't ask him, do you take any tricks it?
You don't know what you're talking about, just say you take any drugs which you take for any inflammation like rheumatoid arthritis. That's your third question. Are there any other drugs which you think need to be asked, or is that mainly they'll be axilo Latinos medications, steroids, steroids among medical medication, you know, they can take anything. So let's say steroids is important.
Anti-inflammatory drugs like me to track some important and blood thinners important, right? Yeah and then I ask him, have you had any surgery, which has left you with any weak wound or sore area, right? You agree is an important question. Yeah, that's important. And that's all I ask in medical history. Then if he offers for thyroid and things, then I get it.
You know, you can't ask everyone, everything. And the last thing I end with socialist or socialist streak, I ask him, you said you were a plumber, you still work or do you have people to work for you? All right. So that's one. And number two, you smoke. Your smoking is important. Yes high risk.
And number three, are there any activities you have stopped doing only because your left knee pain, because people may stop playing golf because the golf partners have died, but doesn't mean you have to do a knee replacement for them? Yeah, you do it because they get pain in the left knee and that stops them. So they're very direct question here. And that's how I end.
So you can co-morbidities. Leading questions, please, Mr. MacFarlane said, if you start opening questions, you'll end up nowhere and you waste the whole five minutes leading questions, focusing on three points. Previous Joint Surgery ask the patient have you had previous joint surgery? Have you had any complications? And that he would tell you the wound infection or so forth?
Thank you very much. That's a good point. I have never thought of it, but I want to say it. I want to. I want to make sure I say it. Thank you. Very good. I understand this. Previous Joint Surgery.
Any contraindications to operation, recent MRI or stroke. And any comorbidities that affect the outcome. So these three things, yeah, joint surgery, comorbidities that would be contraindications or comorbidities that affect the outcome. You don't want that one last question is there anything else you want to tell me? They might tell you, Oh yes, I had the TB when I was three years old.
They might tell you things that you never thought about. And they might say, well, you know, you never asked me, you know, you just have to ask them. And they were some volunteer that information. So it's worthwhile. There could be the question that makes you be what you once said. So what I would say, then make sure we end with Sean's last statement.
I will make it clear that I do it next time, and we will say that summarize for the patient. And this is what one is telling you is exactly what I'm going to tell you later on is the most important person in the room is who is the patient? All right, it's not the examiners, it's the patient, and you have to summarize to the patient. So that's a nice way of summarizing it. And then let's all ask the question have I missed anything fantastic, ron?
Thanks for that. So that leaves me with that. All right. We're on history. Thank you. So let's one good point, and that's what I want to tell you. Let us most likely and because I've given the examiner 25 years ago, people who them earlier will testify that for short cases that we want, most likely the patient is prepared for you and you are all right for short cases.
There'll be no shorts or a skirt, you know, ready for you on a bed, right? For an intermediate case, it's very likely the patient will be sitting in a shirt and trousers, right? Very likely. Hence, I want you now to ask him, you're not going to do it on screen. Don't worry, he's not going to strip, but that's what I think that is.
But imagine what are you going to tell him him if I can go out some underwear? So can you take the toggle off for me, please? Yes OK. No can you please stand up and I'm looking from the front on inspection looking for 1 minute. I know you are going to, but when are you going to inspect these shoes or have you forgotten truthfully?
After the gate, I would do the inspection. That's what I know. And looking from the front, side and back, you see shoes, the shoes. All right. You agree to that as well. Yeah so everyone, so what I would suggest is just memorize it, practice on your wives of family members. Mr smith, you mind removing your trousers and your socks and shoes and please pass me your shoes.
And do you have a stick? You know, look around like that. You have a stick. Now you make the statement. You never forget to stick and walk. You never forget shoes, and you'll never forget to make him undress. You're happy with that. Yeah so please tell him that again.
I want the same statement. What I said to Mr smith, do you mind? Do you mind taking your trousers off in your shoes and your socks off as well? I'm looking for a stick. And ask him, not looking? Just ask Mr smith, you have a stick on a stick. You know, on as if you're asking him who is the most important person, the patient focus it on him.
So ask you, Mr hair, do you have a. Mr smith, take your trousers off and also your socks and shoes, please, and do you use any stick? And then say, please pass me your shoes. They forced me and I look, why? So it's while he's undressing. Happy enough?
Yeah and next, we'll do. What do you want to do next in your big headache? You want to do gait or inspection the front from describe shoes for the exam and get away with a lower limb for all the excitement. The way you do this? Imagine now your patient is undressing, right, so you can't do anything else. So it's a good time to see shoes you agree on.
What? Yeah. So you pick up the shoes. Watch what I'm doing now. What am I looking for? Now look at it. Can you see that there? Yes, we can see which can't see the shoes. Yeah so what am I pointing to?
So the first thing I say, the more here is the green. That's the correct word. Yeah then I put my hand here, and I put it inside. What am I looking for with my hand in here? It's for an internal. Hillary's happy. Yeah then I put my hand inside the medial arch, and the word I'm going to use is there is no medial arch support.
Yeah so why am I saying this? We all agree that passing the exam is not speaking English correctly. It's speaking the language of Watergate. So are these direct words or other insoles. So there's no external heel support. There's no heel, there's no medial support. When I turn the shoe over this and I say there's no due where I turn on one side compared to the other, I'd be happy.
Good phrase. And there is no stretch suggestive of a bunion or a bunny in it. Right? so can you repeat that? So there's no start again. There is no external that there's no internal injuries and there is no asymmetrical way of looking from the back. There's no bunion.
No, I don't know that there's no stretch suggestive of a bunion or a bunny in it. Yeah OK, now you don't have to say all this, but at least you can make your effort of actually looking at it correctly. All right. But what I don't want you to do is don't just pick up the sheet as if you're halfway through this. Look at it and then throw it away.
We're looking at you. Yeah, Yeah. The point I'm going to make for you, for the clinical exams, this is not marks. What we do is we are going to watch every move you make is correct and you can't say something and do something and say something else. All right. So if you're looking at shoes, don't look at the front of your shoe and say there's no asymmetrical way.
How can you look at the asymmetry from the front? You agree what I'm trying to say. Yeah, OK. So do it all that. Yeah, good. So that's where we are, for sure. And then I progress to inspection and clinical findings, which I think we can be over one. You can do it.
I just wanted to give a flag off something. And if it works well, we can do it like we discussed last time. I think it worked very well. I just ignored the examiners. Really ignore it, like what I'm doing in my clinic. And I got this from examining the students because as an examiner. When I see a student coming to me, just looking at me and doing like this and.
My first impression that this country is not confident, but the candidate who comes listen to me say after I tell him then. Even been looking at me and just concentrating with the patient, I would really, really respect this candidate and this is what I did in my exam. The other thing I I, I started to work on establishing a rapport with the patient quickly, and this is exactly what Sean said more or less I start to make like we are friends.
Hi, how are you today? I was just a quick question in two seconds. Was this your new was usually OK today to come over here to the hospital? And I'm sure the examiner and the patient would just both get relaxed because you are now a professional consultant, you are. You are talking to your patient and taking care, even how and what is comfortable now.
Fantastic very correct. I can't. I can't agree more. Yeah so and make jokes. If you if there is something about jokes, make jokes. No problem, ok? If you are examining like something and will be ticklish, oh, be careful. This will be ticklish.
And then crack a joke. No problem. At the end of the day, what I've noticed that it is, it is not very formal. And even if you miss something but you establish this report and you made the patient, that is the examiner will be at ease. And then you will reach quickly to the answers. He will not play with you much and the patient will help you.
So these are my simple tips. Establish, report, ignore the examiner while you are talking to just concentrate as if you are in the clinic and actually think about the examiner as a medical student and you are showing him how you are doing this. That's it. Thank you. Thank you.
To build on what Sam said to a couple of points where you guys can get into trouble without realizing you got into trouble, your examiners will ask the patient what they think of you at the end of the exam. If you have a patient, if you think something is going to be painful to them, turn around, turn around to your examiners and say this part of the exam will be very painful for the patient or will be painful for the patient.
I do not wish to inflict pain on this patient in this scenario. In in this setting, they will say no, go ahead and then it's on them, but you take care. If they wince, you stop. Just say I'm not comfortable. If they usually say no move on, leave that step. But they recognize the fact that you said that is painful. For example, a patient who potentially has CRP. Yes, I said this might hurt if I touch you.
Is it OK to touch you? I didn't actually touch the patient until I checked. They have pain there, and then I rub the leg and they say, what are you looking for? I'm looking for crops. They like the fact that I ask permission first before I did it. Ok? absolutely.
These are very, very important thing. They are not simple tool. They are essential and they are passed on. For some people, that's what some people don't know why they fail the exam. They said, oh, I only had the case of knee arthritis, but we see every day in clinic and I ask all the questions and they surprise why they fail. All these points are more important to the examiner because we all know that the patient has knee arthritis from the minute they get into the room.
But all these points are for safety. They're looking for a safe surgeon who will respect the patient dignity of the patient and is safe. Also safe means they will offer the write operation for the right condition. So yeah, these are essential things. So Virgil, I. So the takeaway message with all of us is that from today onwards, there is no way that the examiner is important.
And that's a fundamental difference between trainees and non to a certain degree that we really worry too much that the examiners will. There's a problem with. We are focused too much on the examiners and all of us have said that you will focus from today onwards only on the patient. That's your main rapport to have with. And I also like a point that when the unrest, I always say, please have a seat or you look after them.
Another point for the history you are. Now take a history. If your standing and the patient is sitting right, ask for a chair. Tell the examiner, please, I need a chair. You pay 2500 pounds for the exam. The least you can get is a chair. All right, so ask for a chair and sit down. So no standing.
I want. Husam says you absorb everything, change your maybe some of us need to change the behavior even. Yeah, it takes time. It's not easy to adapt. So that's brilliant. Thank you very much. Excellent I think if everyone is happy, we will end this session.
We could go forever and think tomorrow morning about it, have to end at some point. So thank you very much, Mr mvala. Thank you. Thank you for your input here. You're making a huge difference to everyone who is attending. Thank you, sir. Thank you. And I'm sure we all appreciate it, to be honest.
And Thanks again to Sean, who came straight from work and has some set of flies, those joining us from his international candidates. He's joining us from Saudi Arabia, where he's his pastor. He's now supporting us and. The attack was left at the moment, but there also was here to start with next week we'll be watching and hopefully we'll be able to offer you more practice again next week.
Thank you, everyone, and good NIPE. Thank you, Allen. Thanks again for bye bye. Bye bye.
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