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Hi, everyone just checking if you can hear me. Let me know if you can in the comments. Ok, perfect. So I think we'll make a start, apologies. I'm on two devices. So the camera is coming from my ipad and the slides are coming from my laptop. So if I'm looking in a different direction, that's why. Um So thanks everyone for coming. Um I'm just going to share my screen. Um and then if you just let me know if you can see it, um hopefully you'll be able to um and then we'll get going and if people trickle in then that's ok. Um So hopefully everyone can see my screen. Yeah, perfect. Ok. So thanks everyone for coming. I know that it's the holidays. Um and it's really close to Christmas, but hopefully this will be useful. Um So we'll be looking at M SK for finals today. Um And my name is Karen and I'm currently in F one, and I was on general surgery and now I'm on Psychiatry. Um, so just some kind of housekeeping things. So obviously this doesn't replace any formal teaching from your university. Um Code blue is an independent platform led by students. Um And we're also partnered with the I FMS A um S and also GKI medics and we'll be using some ki medics tools um for some OSK practice later on. Um And if you want 10% off some cool gki medics things, um we also have a code blue oy discount code there as well. Um So today, in terms of the overview of the talk, um there's quite a lot to fit in because it's all of rheumatology and all of orthopedics. So I've tried to pick the highest yield stuff. Um There's quite a lot of stuff that you learn, but it mainly comes up more in MC Qs and not necessarily OSK, whereas there are certain topics that they love kind of just rotating through OSK. Um So we'll look at how to take an M SK history. Um But mainly the things that differentiate it from a normal history because everything else you do is pretty much the same. There's just a few key things that you would ask about for an M SK history that you might not for a different one. Um We'll also quickly just recap M SK examinations, obviously um over medal, it's impossible to kind of teach properly how to do the examinations, but just tips and tricks that will help you boost your marks in your OSK. Um And then we'll also talk about joint fluid analysis um and also a little bit about X ray interpretation. Um And then I've kind of just put on some slides for the key conditions um that you need to know about for rheumatology and orthopedics. Once again, this isn't an exhaustive list, but it's kind of common topics that me and some of my peers, um, we went to Manchester, but it's kind of applicable to other UNIS as well have seen kind of come up year upon year. Um And they're also really good to just make sure that you're able to take histories for these conditions and also explain them. So we'll talk a bit about the different hearts of arthritis. Um A bit about ankylosing spondylitis and a bit about gout and pseudo gout. Um And then in terms of orthopedics, it's very difficult to pin down specific kind of conditions. So we'll just talk a little bit about hip pathology, knee pathology and arm pathology. Um But the main kind of um bulk of this talk is osteopro. Um And then obviously any questions um and feel free to pop questions in the chat as we go along. Um OK, so first of all, we'll talk a little bit about osk skills. Um So first of all, we'll start off um talking about how to take your history. So, like I said, you take these histories as you would any other. Um But there's different questions you'd wanna ask for a rheumatology history compared to an orthopedic one. So, in terms of rheumatology. Um The kind of key thing that you wanna know about is whether there's any pain. Um And if it's a room history, your patient will have pain of some sort. Um And then if they have stiffness, you want to explore that stiffness a little bit more. So, first of all, working out how long it lasts, um and your cut off point is half an hour. So if it lasts less than half an hour or over half an hour, that will help you gauge whether you're thinking what differentials it might be. Um, and also when does it come on, is it something that comes on but then is relieved by exercise? Is it something that comes on and doesn't go? Um, and is it something that's kind of worse in the evening or the morning? Because once again, these will help you decide what you're potentially looking at. Um, it's also really important to think about skin changes and nail changes. Um, and also to ask whether they've had any swelling. So if you're thinking about something potentially more inflammatory or infective, um, and also just asking about dryness, so it tends to be eyes that get quite dry. Um, and also the throat. So they might not necessarily tell you they've got a dry throat, but if they say that they've got a new onset cough, then you can explore that a little bit more. Um, and it's important to kind of screen for crest symptoms as well. Um So to be honest, for an O you, this is the least likely to actually be the diagnosis. But it's important because if you can show the examiner that you're trying to rule out these certain things, then it will boost your marks because this shows kind of just a level above your kind of baseline standard questions. Um So you can ask about skin changes for your calcinosis Um and also fingertip changes for your Raynauds Syndrome. Um And then for your esophageal motility issues, you can ask about swallowing difficulties and it's important to ask about solids and also liquids. Um just because someone can swallow solids, ok, doesn't necessarily mean that we can swallow liquids, ok, and vice versa. Um And then you also want to know about skin changes once again for any sclerosis. Um and then any new blood vessel formation for te ectasia and the patient might not necessarily say they've got new blood vessel formation, but if they notice that they've got um kind of new redness on their skin. If you examine them, then you can tell that they're new blood vessels. Um And it's also really important to always do a full review of systems because there's lots of conditions um like sle that can manifest themselves in lots of different ways. So you might actually kind of get someone who's got an issue with their kidneys, their stomach. Um and also having neuro symptoms and actually it's a, um, but obviously in an Os, the kind of writers and stations appreciate, you don't have time to ask about every single body part, but just showing that you're kind of trying to do a review of systems is always good to do. Um, and then it's also important to check the immune status of patients. Um, if you're considering putting them on dmards, for example, um, it's just important to know whether they're immune compromised or not. I'm just gonna switch my speaker. Um, let's just, I'm on my laptop now. So, huh. Let's see. Is it better now if anyone just wants to put in the comments, whether it's better or worse or the same? Ok. I'll try bending in hot and hopefully that will make it a bit better. Ok. So hopefully that's a bit better now. Um, so in terms of kind of orthopedics, if your patient presents with a fracture, then you need to work out what's happened to lead up to this fracture. So what happened before? What happened during? And also what happened after? Because if you come in with a fracture, usually nine times out of 10, they've had an injury or a fall. So it's difficult to get to the bottom of what's actually cause this because you can't really just diagnose a fall in a patient. You want to get to the bottom of why this actually happened. Um So it's also important to ask about occupation and the social history. Um So for example, if someone has had kind of a meniscal tear and they're gonna be immobile for 3 to 6 months, but their job relies on them kind of being physical thinking about how you can support that. Similarly, if someone's a carer, um you need to kind of think of ways that you can help the patient. Um and it's also important to screen for previous pathology um and also surgeries in patients because this is gonna affect your examination findings. So for example, if you're gonna do a knee exam on someone, but you find out that actually they had a knee replacement 10 years ago, then you're not gonna feel all of the structures that you would and kind of a native knee. Um and similarly for things like hips. So it's really important to know that before you start feeling um especially in an oy, because if you start saying you can feel things that you just wouldn't be able to feel if someone's kind of had a replacement, then you know, you're at risk of failing the station. Um And if they give you imaging as well, it's really important to check if there's previous imaging to compare the most recent scans to, there might not necessarily be that. Um But in an ak if you kind of show that you're thinking about it and that you're asking for it, that's good um to do because it just shows once again you're going that extra step. Um So in terms of M SK examination, so there's lots of different examinations you have to know. Um And obviously there's not time to go through all of them, but the good thing is that they will follow the same basic structure. Um And if you examine the patient in an organized way, then you're less likely to forget stuff. Um So the first thing is general inspection at the bedside. Um So looking for say walking aids, do they have any orthotic shoes? Do they have a walking stick? Um, stuff like that? Um And also any medication, sometimes patients just kind of have little bottles and vials on their table. So if you can see what they're on, that will be useful. Um And any leaflets say someone has just been recently diagnosed with something and you're going to speak to them um on the ward. Sometimes they want to know more about their new condition or they want to know more about this new medication that they've been started on. Um So if you kind of clock that, then it's worth just asking the patient more. Um And then you wanna do a general inspection of the patient and for an osk, you can include a brief history if you think it's gonna help. Um But it kind of really depends on the situation and it also depends how much time you have. There are some um kind of M SK exams that are really time pressured. Um So for those, it's better to just get started. Whereas if you're doing something like a gals examination doesn't really take that long. So you can put in a bit more of a history if you want. Um, and as soon as you generally inspect the patient, you'll be able to see whether they appear to be in any pain or not. Um, do they have any casts or slings or crutches? Um And can you see any obvious signs of trauma? So say, for example, you can see loads of blood everywhere, you can see a massive open wound stuff like that, then that might lead you to kind of thinking about what brought the patient in. Um and then also body habitus. So for example, some conditions are more likely to happen like gout um or uh adhesive capsulitis if you're obese. So kind of thinking about whether that has had anything to do with their presentation. Um And then look for your move is the key bit of any M SK exam. Um So when you look, you want to make sure to check if any changes you see are bilateral or not. Um So is it kind of a mono arthropathy compared to a polyarthropathy? Um And in terms of feeling, you really need to take your time to feel superficially and deeply. Um because this is the bulk of your examinations, things like special tests for example, if you run out of time, you can kind of just describe them, whereas you can't really describe feeling and if you don't feel it properly, then you're not gonna be able to come up with a decent differential in the end. Um And then in terms of moving, so always remember to test both active and passive movement. Um and don't forget to do a gait assessment if it's relevant. Um So for most of the kind of lower limb examinations, a gait assessment will be useful. Um And obviously, if you're doing your gals, that's kind of one quarter of it. Um But for things like kind of shoulders and stuff like that, you don't necessarily need to, but for things like the spine, you would. So if you've got time, it doesn't hurt to do a gait assessment. Um And when your testing look, feel, move, always remember to test the joint below and the joint above. Um usually in os the examiner will kind of just tell you to move on, but it's important that you still offer to do it because sometimes they do actually want you to do it. Um And you don't want to miss out marks just kind of by skipping ahead and then finding that you've got time at the end. Um And then there's lots of special tests, these ones that I've put on the slides are kind of just a mixture of them. It's not an exhaustive list. Um But it's really important to kind of categorize them in your head to kind of like upper limb and lower limb tests. Um So for example, if you're doing the scarf test, that's only going to happen if you're testing the upper limb compared to if you're doing Thomas's tests, if you're testing the spine or the lower limb. So, stuff like that. Um And you don't need to do every single special test under the um sun, you just need to do one or two to kind of show what you're looking for. Um And explain what you'd expect to find. So for example, when you're doing the painful arc, what would you expect to find at 90 degrees 100 and 20 et cetera? Um And then the final thing to do is summarize your finding. Um So when you kind of talk about the patient, you've seen you wanna put in their name and their age. Um But if you can't remember their age, it's fine. It's a nosy, it's very stressful. Um You're not gonna get marked down necessarily, but having a rough ballpark. If the patient 18, you say they're 20 then obviously it's better to just omit their age. Um and also present your findings chronologically and it's really important to put in relevant positive and negative findings just because a finding is negative, it doesn't mean you just ignore it. You still need to put it in. Um And then obviously, you want to suggest you most likely differential and also the next steps for treatment um in terms of joint fluid analysis, there's not too much to say on this. It's kind of just a case of learning. Um So the easiest way to learn what you're looking at is a table like this one. And I mean, in terms of he arthrosis, um this one, they don't tend to put in a key because as soon as you see that the color is red, it's quite obvious. Um But I mean, for the purposes of MC Qs, it's still important to know. Um septic arthritis is also kind of a good one to know which it kind of makes sense because you see an elevated white cell count. Um and then you also kind of see cloudiness which, you know, you can kind of associate with the bacteria. Um and also yellowy green, usually kind of a medicine. If things are yellowy green, it kind of points towards an infection somewhere, especially the green bit. Um So that's an important one to know. Um It's also important know what normal joint fluid analysis is because there's nothing to stop them giving you normal joint fluids and kind of you then getting tricked into thinking there's something wrong. Um And the biggest giveaway is that normal joint fluid should be colorless because if you think about it, if there's nothing there, your white cell count should be low um and your there should be no discoloration because there shouldn't be anything there to discolor it. Um And then in terms of noninflammatory and inflammatory cause. Um So really, you want to have a look at whether it's translucent or cloudy. Um And then also see whether there's crystals or not. Um And if you do that, you can't really go wrong. Um And in a nosy, it's important to just talk through each bit, to kind of discuss the color, the clarity, the viscosity, et cetera. Um Because then even if you come to the wrong diagnosis, at least you've shown you've kind of methodically thought about this. Um So the next thing in terms of X ray interpretation, so to be honest, the x-rays, they tend to give you in acies are quite kind of common ones. They're not gonna give you anything too wild that you would need intrinsic orthopedic knowledge to kind of decipher. Um The most common ones tend to be neck and femur fractures. Um But they might give you a name. Um So first thing to do is look at patient identifiers. Um So things like the patient's name, date of birth and then either hospital or NHS number either is fine. Um And then also the scan details are really important. So when was this image taken, was it taken yesterday or was it taken five minutes ago? Um And then looking for any previous imaging because like we said before you always want to try and compare previous images. This might actually be pathology that a patients just always had and it's chronic compared to something that's new onset because you'd be more concerned if it's acute. Um And also having a look at what views are available, usually you wanna try and get two different images because say, for example, you've got a fracture on one kind of angle, it might actually look fine. And then when you look on another angle, you see actually that there's kind of pathology there. Um But obviously, in kind of some instances, it's not always um possible to do that. Um And then you also want to have a look at what you're actually looking at. Um really in an ideal world. If you're having a scan, you should also have the joint above and the joint below, but that's not always possible clinically. Um And then also having a look at whether the film is adequate. So um is there sufficient exposure? Is there sufficient kind of rotation? Um et cetera. Um And then in terms of the things you wanna look at, so you can narrow it down to ABC S. Um Once again, in terms of an osk, you wouldn't necessarily actually be doing this. But if you kind of start to offer to the examiner that you would be looking for these things, they'll kind of prompt you along. Um And you'll also be scoring the highest marks which is obviously good. Um So you wanna have a look at whether the joints aligned or not. Um Because if it's not, then you might be thinking a fracture or a displacement. Um And you also wanna have a look at the joint space. So, uh there are new kind of things that are formed in the joint space, like kind of bony lesions or something, um or tissue um Or whether it's actually narrowed and you've had destruction of bone or joint because that's also really important to know what you're looking at. Um And in terms of the bone texture, um so, I mean, kind of looking whether there's any obvious discrepancies in density. So for example, if you've got kind of two scans side by side, having a look at whether one shows marked osteopenia compared to the other one. Um And then in terms of the cortices, so if you just get your finger and you trace around the image, um then obviously you want it to be a complete line and as soon as you see any breaks um or areas of deviation, then you know that you've got a fracture somewhere um no matter how big or how small. Um and sometimes it's really obvious to see areas of greater destruction if your patients had massive trauma. Um And then it's also important to look for soft tissues. So checking for any foreign bodies um or any effusions or swellings. Um And if there's a fracture, then you need to state whether it's complete or incomplete. Um And whether it's open or closed. Um And also whether there's any displacement or not. Um And it can be really difficult sometimes to kind of remember all the different types of fractures. Um But I think the best way to do this is kind of just learning through diagrams. Um because when you have a look at all of the different types of fractures, these are the main ones you kind of need to know. Um So, I mean, green stick is only relevant in Children. Um But I mean, you know, for the purposes of an you just knowing things like you're closed and you're open. Um and then kind of knowing the implications of those is sufficient. Um And they tend to, like I said, give you quite, quite nice ones. They're not going to expect you to spend like five minutes analyzing it in detail. You'll usually be able to tell what's wrong straight away. Um And then it's just about being able to give you answers in kind of a logical formation. Um So I won't spend too long on this slide. Um But you can have a look at it in your own time if you wish. Um So now we'll quickly just spend like 15 minutes talking about your key differentials for M SK. Um So I've split it up um into kind of rheumatology um and orthopedics once again, this isn't a kind of um extensive list, but it's all the kind of main conditions. Um And I've just put literally kind of a few bullet points. Um That kind of gives an overview of the condition because to be honest, at this point in final year, you're probably busy prepping for your exams and there's no point teaching you guys stuff that you already know. Um But there's no harm in recapping it and it will also be useful. Um for some ki practice a little bit later. Um So in terms of your arthritis, you've got four different types which we'll discuss. Um So one of the most common ones is osteoarthritis. Um, and it tends to affect your big joints, so your hips, your knees, your spine, your hands. Um And it's noninflammatory. So you can kind of think of it as just nature's wear and tear really. It's, you know, some people see it as kind of almost like a natural process of getting older. Um And it presents with joint pain and stiffness that worsens with activity. Um And this is really key because some other forms of arthritis, actually, if you kind of start using the joints, you loosen them up and that actually improves. Um And on X ray, you show you can see degenerative changes. Um So you'll see that the joints is lost. Um And then you'll also see osteophytes which are little bony spurs, um, kind of starting to be produced. Um And then you can also see sclerosis and subchondral cysts. Um And these are kind of like the four Hallmark presentations um of osteoarthritis. So it's worth just recognizing those key phrases in case you see them in M CQ stem. Um And then you can also see things like Heberden's nodes and Bouchard's nodes. Um and also the squiring of thumb bases. Um which if, for example, you've got a patient in an AY and you do a hand exam on them. Um If you notice these things, kind of tell the examiner and pick up on them, don't be afraid to kind of use terminology and to kind of say what you're thinking, even if you're not 100% sure if the thoughts come into your mind, then go with your gut and think because it's probably right. Um So in terms of things that you can do for osteoarthritis, um, it really depends on the patient if they're kind of otherwise fit and well, um compared to, if they've got lots of comorbidities, um and you know, they're kind of close to housebound. Um So something that you can do is encourage weight loss cos if you think about it, if your joints are already under strain, um, the more obese you are, the bigger strain they're gonna be under. So a bit of weight loss kind of obviously diet and exercise because if you've got someone who it hurts when they do kind of activity, you wanna encourage gentle exercise, but make it clear to the patient, you're not kind of asking them to go and run a marathon or something. Um And then walking aids is really important. Um kind of just supporting the patient with still being as mobile as possible because once they start being mobile, you kind of see a massive decline in patients quality of life. Um and also kind of what you can actually do for the osteoarthritis. Um and then home adaptations. So for example, having important things on a ground floor, um kind of not having very sleep stairs, stuff like that. Um And usually you just give the patients nsaids. Um So you can, if it's say, um on the knee, you can give it topically. Um But otherwise say, for example, if it's on the spine or the hands, then actually oral nsaids might suffice. Um But that's kind of the first line, um kind of treatment. Um And you can give intraarticular steroid injections if the NSAID s aren't covering this. Um And then your kind of last resort really is surgery. But once again, it really depends on the kind of individual, um whether they're actually gonna be fit for anesthesia, whether they're gonna kind of recover from POSTOP complications. Um So it's kind of a case by case basis. Um And then in terms of rheumatoid arthritis, so it's autoimmune and it's basically where you've got chronic inflammation in the joint synovial lining. Um and usually you get symmetrical polyarthritis. Um So polyarthritis just means that you've got more than one joint involved. Um and symmetrical kind of is self explanatory. Um So it can be acute um or it can be chronic. So you can see someone having an acute flare up for the first time, they don't know what it is, they come get checked out, get the diagnosis. Um or you can see someone who's had it for say 30 years, um, and is just managing it on medication. So you get a real spectrum with rheumatoid arthritis. Um And the kind of classic finding when you examine someone with rheumatoid arthritis is that their joints feel really boggy, um because their joints are really tender and they've also thickened. Um So when you palpate them, it kind of moves around, um, and it feels when it's kind of like a swollen grape. Um So once again, M CQ, if you see bogginess of joints, that's kind of giving you a clue. Um, and things that it can, um, present with so it can present with bouts. Um, and also Z shapes and swollen neck deformities, um, and also ulnar deviation. Um So it's just important to remember the differences between osteoarthritis and rheumatoid arthritis. Um, and some common risk factors. Um So women are more likely to get rheumatoid arthritis. Um, smokers are people who are obese. Um, if there's a family history of rheumatoid arthritis. Um And also if a patient has other autoimmune conditions. Um So it's important if you're taking a history to screen for other autoimmune conditions, um but have a few in your head that you're thinking about because if you ask a patient, do you have any autoimmune conditions? Most of them won't know specifically what those are. Whereas if you ask them about specific conditions, you're more likely to get a positive answer. Um And it's also associated with the HLA AD R four gene and in terms of monitoring it. So there's a das 28 screening tool. Um So that kind of shows you if it's getting worse, if it's getting better, the 28 comes from 28 different joints um that you kind of assess. Um and that will help you see whether a patient needs escalation in the treatment or actually if they fine as they are. Um And in terms of antibodies, so you've got your rheumatoid factor, but actually anti CCP antibodies are more specific and more sensitive for rheumatoid arthritis. Um So it's worth just bearing in mind kind of what you'd expect to see on an antibody screen. Um And if you see someone's x-ray, then you'd expect to see bony erosions and also some osteopenia. Um and you manage rheumatoid arthritis using steroids and also DMARDS under the supervision of a rheumatologist. Um And then in terms of psoriatic arthritis, there's not too much to say here. Um It's an inflammatory arthritis. Um and it's obviously associated with psoriasis. Um So it's a seronegative spondyloarthropathy and it presents with lots of psoriatic plaques. Um And patients can also have nail pitting and also oncolysis, which is where you've got kind of the nail bed almost coming away. Um And patients usually develop arthritis within 10 years of receiving their psoriasis diagnosis. Um So if you've got someone who has recently been diagnosed with psoriasis and then starts to get joint pain and stiffening, you can think about psoriatic arthritis. Um And it's also associated with IBD and uveitis. Um So if you meet and they kind of say that they've got these symptoms. Um and they've got psoriasis, it's always worth asking about kind of any abdo symptoms. Um and also any f symptoms um in your review of systems. Um And there's also a screening tool um which is called test. Um And it kind of once again just helps you see how severe the condition is in a patient. Um And what interventions need to be made. Um And on an X ray, you tend to see osteolysis um and also um ankylosis. Um and it's an MDT approach by rheumatology and dermatology because you want the psoriasis to be under control, but you also want the arthritis to be under control. Um So, between them, they can decide a management plan, but usually you give them NSAID s, you give patients steroids. Um and then you can also later down the line and consider dmards and anti TNF medications if nothing's working. Um, and then finally, we've got reactive arthritis. Um, so this is basically sinusitis because of an infective trigger. So if a patient recently mentions they've got gastroenteritis, um, or they've had an S TI um, or they mention that they're HIV positive. Um, and they've got all these kind of symptoms, you should start to be thinking potentially it's reactive arthritis. Um And the common, one thing that, you know, you can remember it by is they can't see P or cli tree um because it also presents with anterior uveitis, um bilateral conjunctivitis and also urethritis. Um So it's worth if you're going to ask about symptoms, definitely asking about these ones because if they say yes and they've had a recent infection, they've basically spelled out what the diagnosis is. Um But this presents very similarly to septic arthritis because they're both um infected in nature. So it's really important to start the patient on antibiotics before you've excluded septic arthritis because if you delay giving antibiotics, it's going to get even worse. Um And the initial management is treating what actually triggered the reactive arthritis because if you can treat the cause of the infection, then you can treat the arthritis. Um But if this still doesn't work, then the key thing that you can't always rely on is nsaids. Um And also steroids. Um So just a little bit about ankylosing spondylitis. So, it's an inflammatory condition and it usually affects young males to kind of between 2040. Um And it affects your sacroiliac and vertebral column joints. Um And it's linked to the HLA B 27 gene, which is really important to know for your MC QS. Um And it kind of usually comes on quite gradually over a couple of months. Um and it presents with lower back pain um and stiffness, um and also some Sacroiliac pain. Um But the key thing is that it can also present with chest pain, shortness of breath and dactylitis. So if for example, you see someone and they are initially complaining of chest pain and shortness of breath. Um but it doesn't seem to be anything kind of cardio respiratory. It's always worth just asking about any back pain or stiffness because if they say yes, you can kind of explore that avenue a bit more. Um And with an b the pain is worse at night. Um and the stiffness takes at least half an hour to improve in the morning, but eventually it does improve. Um And the symptoms are better with activity and worse um with rest. So kind of a key um stem is like a young 20 year old guy plays football, feels fine and then as soon as he stops playing, feels in pain, why? Because it's an bond. Um And then you can see um on the powerpoint here, there's an X ray, this is bamboo spine because it looks like a piece of bamboo. Um And this is um kind of diagnose diagnostic of anx bond. Um So it's important to kind of know that bamboo spine equals an bond. Um And in terms of how to treat it, so you consider physiotherapy um and also encouraging the patient to er undertake smoking cessation if they do smoke. Um And you can also give them bisphosphonates if you're really concerned um about them kind of have a low bone density. Um And you can also encourage exercise because exercise relieves the symptoms. Um And you can also give them NSAID S and then consider anti TNF medication if you feel like nothing else is working if you've not really had much luck with lifestyle and kind of just some nsaids. Um and then in terms of gout. So, I mean, this is when you've got deposition of urate crystals in your joints and that causes inflammation. Um So the risk factors are being male, um having a diet that's high in alcohol. Um and also being obese, um concurrent use of diuretics, um having a diet that's high in purine. So things like chicken, for example, and also having preexisting kidney disease, um and it usually affects the big toe, but it can also affect other joints like your thumb, bases, wrists, knees and ankles. Um and you can get gouty toe fi on surfaces like your ears, your elbows and your hands, and they've included the picture um on the side just so you kind of remember what it looks like. Um And in terms of joint aspiration. So it's important to be able to tell the difference between gout and pseudogout. So if you've got gout, then you're gonna have needle shaped, negatively by fent crystals. Um And if you've got pseudo gout, then it's gonna be rhomboid shape. Um And they're gonna be positively bent. So this comes up every single year in MC Qs and it's really easy to put in an AY as well. So it's worth just learning and learning. Um And X rays will show actually normal joint spaces, but you can also get punched out erosions and lytic lesions. Um So, in terms of acute flares, once again, as per everything you can give the patient nsaids. Um And you can also give them colchicine as well um and oral steroids if you feel like it's needed. Um And then prophylaxisis is managed with allopurinol. Um So even if someone's not currently having an acute flare to stop one happening, put them on allopurinol and hopefully, things will be OK. Um And then just three quick slides on kind of um orthopedic kind of um pathology before we get to the osteopro. Um So, really for hip, we're thinking neck a fema fractures um and they can present with groin and hip pain and sometimes it can radiate to the knee. So actually a patient might come in with knee pain. But then when you examine them, you find out that actually the trauma has happened to the hip and it's just radiated. Um, patients also have an inability to weight bear. Um And the kind of key classic snippet for an M CQ is having a shortened, abducted and externally rotated leg. As soon as you see this, you can kind of think to yourself that it's a knock. Um And once again, it's really important to establish what actually led to the fall. Um You find in quite a lot of notes, things to say mechanical falls, but you actually wanna find out was it kind of hypotension? Was it an electrolyte imbalance? Was it genuinely just tripping over something? Was it something to do with their medication, et cetera? Um And then you basically got intracapsular and extracapsular fractures. Um So if they're intracapsular, then you've broken the femoral neck within the hip joint capsule. Um And you can classify this using the garden classification. Um And you can treat it either with internal or arthroplasty. Whereas for your extracapsular fractures, your blood supply of the neck of femur is intact. So you don't need to go down such an extreme route in times of surgery. Um You can treat them just using dynamic hip screws, um or intramedullary nails. So you always want to think to yourself whether the blood supply is compromised or not because that's gonna help you decide what your treatment pathway is gonna be. Um And I've just included the different garden classifications. So it's a stage 1 to 4 scaling system. Um and also just visualizing the different types of hip fracture. So, inch capsular versus extra capsular is quite important because if they give you a neo feur fracture, um x-ray in an exam, it's not enough to kind of just say it's an eif feur fracture. They want a little bit more detail, obviously, as much detail as you're comfortable giving. Um but still the more detail you can give the better. Um And then in terms of the knee, so in terms of meniscal tears, this is kind of a typical presentation when a knee is twisted. Um and patients often report that they hear a popping sound. Um So people that play quite a lot of sports, especially contact sports at some point come with meniscal tears. Um and they usually have knee pain, obviously. Um and that can also radiate to the back. So once again, if you get a kind of young sports person complaining of back pain, always think to yourself is this actually coming from the back. Um and knees can also feel stiff um and also lock um and also have a reduced range of movements. Um So we've already discussed that it can happen in young people who play sport, but it can also happen in older people as well, just kind of via common wear and tear that might just be walking, they might feel their knee give way and there you go, meniscal tear. Um and you can investigate it using MRI and also arthroscopy. Um But really you just treat it with conservative management. Um So kind of resting it also making sure that it's kind of elevated and compressed um and putting ice on it. Um and then you can give nsaids for the pain. Um and also physiotherapy. Um and you can give, you can have surgery but quite a lot of people, especially kind of elite sports people um tend to not want surgery because of the long recovery time. I remember I met a famous footballer when I was in fourth year on my placement who just completely refused surgery because they didn't want to be on the bench for up to a year. Um But obviously, if you don't have surgical intervention, things get worse before they get better. Um So once again, this is just the diagram showing what healthy knee would look like compared to where there's a meniscal tear. Um which kind of as it says on the tin tear in the meniscus. Um So it's just important as well to remember all the different ligaments that can be involved. Um And apart from that, there's not really kind of too much to it, um just remember to always elicit whether there was any twisting or any popping. Um And then in terms of the shoulder, so the two things that are focused on are dislocations and also adhesive capsulitis. Um So, dislocation is when your head of the humerus comes out of the glenoid cavity of the scapula. Um And 90% of them are anterior dislocations. The only time you see posterior dislocations are if someone's been electrocuted or they've had a seizure. Um And it's also important to consider whether a patient's had the ax of the nerve damage. So for example, in your deltoid area, which is also the regimental bad area. If you've got a loss of sensation, you might want to think whether you've got the axillary nerve being compromised. Um And you can acutely manage it with analgesia also just putting the patient's um ominous sling. Um You can also try a closed reduction. Um And obviously, you want the shoulder to be immobile for a short period of time so that it can heal. Um And if you've got a patient coming with recurrent dislocations, so say three or more in a year, often you need to give them physiotherapy and you can also offer shoulder stabilization surgery because if you've got someone who three times a year keeps on having shoulder dislocations, obviously, that's not good. Um It affects their quality of life. Um and it also kind of it, it's just inconvenient. Um And then in terms of adhesive capsulitis. So this is also known as frozen shoulder. So it presents with shoulder stiffness and pain and it can be primary or secondary. So primary just comes on out of nowhere on its own secondary, um, secondary to kind of other underlying causes. Um, and the risk factors are being female. Um Also you tend to see middle aged people getting it. Um, and diabetes is a really important one and also obesity. Um, and there's three main phases. So there's painfulness, stiffness and then thawing. Um So with the pain it comes on, it's really a cute and that's all the patient talks about. They don't really mention it being stiff, it's more just kind of like a constant aching pain. Um And then eventually you go into the second stage where actually, now it's just starting to stiffen up and they can't really move it, but the pain is not as bad. Um And then you've got the thawing stage, which is why these symptoms get better for a little bit. But unfortunately, then you're just back into the next stage, which is the pain and it kind of just repeats itself. Um And usually your X ray is gonna be normal. So you kind of just base it off the clinical history and examination. Um If all the symptoms sound like a des of capsulitis, um when you examine them, you're kind of pretty convinced it is, you can diagnose them. Um and you manage it with analgesia also physiotherapy. And if nothing else is working then intra articular steroid injections as well. Um So that was a really quick whistle spot to some of the key conditions. Um But the kind of the main focus of today is OS practice. Um So there's two practice stations that I've got. Um So the first one is data interpretation and explanation. Um And then the second one is a history taking station. Um So I'll just put up this slide. Um And if someone would like to volunteer to do it, that would be great. Um So I'll let you just kind of have a read of it. And then if anyone wants to volunteer, let me know in the comments. Um And I'll invite you to the stage. So it is a really good time to practice. This is completely something that you could get in your real ay. Um So it doesn't hurt to practice now. Um And yeah, if anyone wants to, yeah, perfect. I would. So I'll invite you to this stage. Um There we go. So hopefully you'll be able to join. Um And obviously because it's data as well, you can have as long as you want to interpret the data. Um And then I will be the patient. Um um Whenever you kind of want to start it, it's up to you. Um I know that obviously in the real thing, you'd have a bit more time to prepare yourself. Um But it's up to you in terms of when you want to start. Um And I'll pop a timer on for eight minutes, but we're not too concerned about the timing for this one because there is a lot to do. Can I just confirm? So, uh in terms of the scenario, am I just kind of explaining the what I think might be happening to the patient? Yeah, essentially. So you've got the joint fluid analysis which should hopefully tell you diagnosis. Um And then it's kind of just explaining to the patient what the diagnosis is. Um and answering any questions that she might have about it. Ok. That's fine. Ok. I think I can start. Yeah, perfect. OK. Um Hello. My name is I'm in A&E could I just confirm your full name and date of birth? Yeah. So my name is Josie Joint and I'm 24 years old. Ok, nice to meet you Josie. Uh this is the first time I'm meeting you. Can you just tell me a bit about what's brought you into? A&E? Yeah. Um I mean, so basically I I've just had a really kind of painful knee and I don't really know why. Um So I kind of just thought maybe you guys could tell me why. Ok. And could you just tell me a bit more about the pain you've experienced? Yeah. So I mean, it's my right knee. Um and for some reason it's just really warm like it's winter. So why are my joints warm, you know. Um, and I think compared to the other knee, it's quite swollen as well, but I don't know if that's just normal. Ok. And in terms of pain, how severe would you say it is? How is it affecting you? Um, well, I can't really walk on it anymore, to be honest. So I'd say about an eight, like when it first started, it was about a four, but now I'm, I'm really struggling to walk. Hm. Ok. And apart from the pain in the knee, have you noticed anything else unusual or any other symptoms? Um, like what, um, so kind of a, any pain anywhere else on your body or is it just in that knee area? I mean, I've not particularly had pain but I have noticed some abnormal discharge as well, actually. Ok. Can you just tell me a bit more about the discharge? Yeah. So, I mean, it's, it's kind of just, you know, feminine discharge, I guess, but it just smells really bad and it's kind of like greeny, yellowy. I don't know if that's normal. Ok. And when did you first notice this? Um, so this happened about a month ago or so, but I kind of never really thought anything about it, but I don't know whether the knee and this discharge connected or whether they're different. I don't know. Ok. And you've experienced this, uh, discharge? Have you experienced kind of, um, any other symptoms like pain whilst you go and urinate or pain in your lower abdomen as well. Um, I mean a little bit of abdo pain, but I kind of just think that's more period pain cause I don't really have that all the time. Ok. And just ask you more questions in relation to the dishes and personal questions if that's ok. And could I ask, are you sexually active at the moment? Uh, yeah. So, um, and can I just confirm it, start with one partner or, um, multiple partners? Um, so a few. Yeah. Um, and do you use protection during intercourse sometimes? Yeah. Um, if I remember? Ok. And have you experienced any sort of sexually transmitted infections in the past? Um, I mean, I've never gotten tested for any, but I don't think so. Ok. And just in terms of your social life, that's ok. Do you smoke at the moment? Um, you know, socially but nothing major? Ok. And do you drink alcohol? Yeah. Yeah, I did. Ok. And how much, um, maybe a few pints a week, a few pints a week? Ok. And in terms of, um, you know, what the knee pain and how, and what's going on. Do you have any ideas what could be causing this? Um, I don't really have any ideas. That's kind of what I was hoping you'd be able to tell me doc. Yeah. Ok. Yeah. So, um, before we go on to the kind of explanation what I think might be going on. Were there any kind of big concerns you wanted to me to address or talk about? Um, I just, I just don't know what's going on. I don't know if these things are connected or not, but, I mean, I'm only 24. I'm not supposed to be hobbling along like this, you know. Ok. Yeah, that's fine. So, while I've kind of explained to you what I believe is causing your knee pain. Um, and in some of the investigation tests, we did to come to that conclusion, you stop at any point or repeat anything. Just let me know I'll be more than happy to stop. All right. Ok. Ok. So what uh what I believe is kind of going on with your knee is I think you've developed a condition, a condition called septic arthritis. Have you ever? No, no, I've not, but that sounds really bad. Um So I'll just give you a bit more information about it and hopefully kind of and how we treat it and hopefully that can calm your nerves a bit uh in terms of what it is. So what septic arthritis is, um kind of breaking down what the words is. Arthritis, meaning, meaning, you know, affecting your joints in, in particular, affecting one of your joints, which is your knee and septic kind of de describing it being an infected joint. So your joint has become infected, especially that joint in your knee. Ok. Yeah. So what we did to confirm is we just took a sample of the fluid, um, surrounding the knee area, um, and had a look to see what that fluid contained and what it showed was that that area was quite, um, infected, uh, was very infected. Um, and that's what's resulting, um, in your symptoms? 00, ok. Ok. Does that make sense so far? Yeah. So what, what are you going to do about it? Do I, do I need to be admitted into a hospital? Can I go home or what? Yeah. So in terms of what we're going to do about, I'll just get, I'll just kind of get on to, you know what septic arthritis is in terms of the symptoms it cause and how we're going to treat it. So, when, when the joints become infected, it results in serious symptoms. It causes your joint to become red hot and swollen, which has occurred in your case. And it causes really bad, extreme pain, pain to a level where you're struggling to walk and you hobble a lot of the time and struggle to weight, bear on it. Um, and because the symptoms are so severe, we need to admit, um, patients in, for treatment, uh, for this condition normally. Yes. Oh, ok. Do, do I have to stay though? Yeah. So, so it, it is very important that you do stay just because of the things that can happen if you do not treat this condition in the hospital. If you don't treat this condition in the hospital, what can happen is at the moment, infections just in your joint, what you can, what can happen is the infection can spread to your blood, blood stream and that can cause you to become severely unwell and cause a lot of the different organs of your body, specifically the heart um to struggle as well. So we kind of we really want to avoid that and providing you with urgent treatment is the way we're going to do it. Oh, ok. Well, I guess, II have to say then, aren't I? Yeah, I do believe it's very important because leaving you untreated can be very harmful, very harmful for you and you don't really want to take that risk. Ok. So what, what else am I going to receive in hospital? How are you going to treat me? So, the first thing we're going to do in A&E is we're going to provide you with antibiotics straight away, um, antibiotics so we can uh prevent the infection, spreading any further uh and kill off the bac bacteria which has resulted in the infection in the first place. Ok. Um We'll also refer you to the joint specialist as well. We'll assess your joint and see if there's um if there's any need of any sort of surgical intervention. Um But the first thing we're going to do is give you the antibiotics straight away. Um, um, to help settle the symptoms you've been experiencing, we'll give you some strong pain relief as well because of the symptoms you've been experiencing. Ok, that's fine. So, is that gonna sort out my knee? And also the discharge, like the antibiotics will do everything. So, uh, the antibiotics, the first thing going to give you, we're going to treat the knee pain because that's the, uh, the most severe of the two symptoms. Um And if left un, that can be life threatening. So we're going to treat that first and then we, we'll get on to help with the vaginal discharge. Um Actually the discharge and the knee pain is linked. Um I believe. Ok. Yeah, so the reason is that in, in some cases uh when the patients have sexual intercourse with our um uh protection sometimes that can result in a, in a, in a infection, a sexually transmitted infection. Um And in certain cases this infection can go to the joint um resulting in the pain you experience. Oh, ok. Yeah, that makes sense. So I guess yeah, they are connected. But yeah. Ok. That, that sounds good. I'll stay then. Yeah, I are you up here at everything and then so far? Yeah, I'm, I'm happy with that. Thanks, Doc. Ok, thank you. Perfect. So that was bang on eight minutes. So that was really good. Um So overall, yeah, that was really, really good. Um So you correctly got the diagnosis which yes, was septic arthritis. Um, as soon as you kind of see a high, high white cell count, um, and also yellowy kind of, um, joint fluid, you know, that you're thinking of some kind of infection, but it's really good that you picked up on the cues. Um, cos at first you can think that kind of the discharge in the knee aren't connected. Um, but they are because it's like we said before, if you've, um, kind of got kind of infective risks anyway, um, then it's only a matter of time really before it develops into something like septic arthritis. Um And it's also just important to ask, um, whether they've got any drug allergies. Um, because then if you're starting someone on antibiotics, you need to know whether they've got any allergies or not, um, or whether they've got any intolerances. Um So that's the only thing. Um And then also just from an osk point of view, um, which does happen in your life as well. Um If they kind of mention that they've got some behaviors, um kind of, I don't know, like smoking, drinking a lot or kind of having unsafe sex, whether they want any help with that. Um So you kind of just offering, um, any community help with that or offering, um, you know, kind of any free contraception, et cetera. Um Just to kind of show that you're trying to encourage lifestyle change whether or not they accept it, you know, it's, it's whatever. Um But just showing that you've thought that extra mile, but otherwise that was really good, to be honest. Um Obviously in eight minutes it's difficult to cover everything, but you explained the examination findings well, and in a patient from the language. Um and you also manage to keep her in hospital, you get this so much where patients are kind of like, oh, I don't wanna stay. Um The only other thing to um always just check is why they don't wanna stay. Is it just because it's inconvenient or because they don't like hospital um or is it say for example, because they've got kids at home, something like that because if you don't ask, they might not tell you, you, you wanna just make sure you've covered all the bases. Um But otherwise yeah, it was really good. She picked up on all the queues and it was really good that you put an ice as well. Um because examiners love it when you put ice in. Um And I mean, for her there wasn't really anything kind of wild in terms of ideas or concerns, but sometimes they might actually be that golden clue to the diagnosis if you're not. Sure. So yeah, really well done. Thank you. Cool. Um So there's one final um station. So this is a history taking station. Um If anyone wants to have a go um I'll just um answer Paul's question is it, uh, necessary to ask about things. Yeah. So in terms of the kind of stems that they give you, they still want you to kind of elicit it. Um, because otherwise it can be really random if you go into a station and say, oh, ok. So I've heard you've had some like vaginal discharge in the past in some of our oy stations, patient has been like, what, what, what you're talking about. How do you know that et cetera? Um So it's good to just kind of clarify with them, especially when it's something sensitive like that. Um because the patient will be brief to kind of obviously talk about it. Um But it's important to kind of just ask them if they've had any kind of symptoms rather than just going in. Ok, so you've had this, this and this cos in real life, even if they'd been triaged and you knew what was going on, you would still ask them to tell their story from the start in case they'd forgotten anything in case it wasn't clocked properly, stuff like that. Um So yeah, always ask, but if they want you to hurry on, the patient will kind of just say, yeah, yeah, that's fine, but like that's not why I'm here type thing. So they'll kind of guide you. Um Anyone wanna do the second station? Hopefully that answered your question, Paul, if not, let me know if not. Um I mean, we've kind of already covered how to do history taking station anyway. Um So doing the first station was kind of, I guess more important for just having a bit of practice at explanation and data. Um It's nearly eight anyway. So if no one wants to do the second station, then we can um there. Um So feedback forms will automatically be sent to everyone. Um And if you fill in the feedback form, um then you get a copy of the slides. Um So there's no QR code cos you'll get emailed it. Um But it's also really useful for portfolio, so it would be much appreciated. Um And if anyone has any questions either about the content from today, about f one about anything, um I'll stay on the call for a little bit. Um But otherwise thank you everyone for coming out and I hope you will have a really good Christmas. Perfect guys. Thank you or any questions, feel free to pop them in the chats otherwise have a lovely rest of your evening. Um So Bianca, the feedback form will be emailed. Um So as soon as the session ends, which like is technically in three minutes, it will just automatically get emailed um to the email that you signed up to this event in.