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Uh uh with any history taking, it's always gonna be bread and butter. Anywhere you go. When you're clerking as a doctor, you got to know your basic is you're taking and I'm sure you would have come across it by now. And it's something that you do on the wards uh probably day in and day out and it's something that you're getting used to and used to and soon sooner or later, it will become just part of uh just rote learning and uh staff basics. So you got to know this acronym and I'm sure you've seen it before. But presenting complaint, history, presenting complaint, ask a few questions around the systems review. So something I always used to get a bit nervous with when I was a medical student. Uh Maybe it was King's didn't sometimes teach it as well, but it was this M S K A systems review. Sometimes you might see documentations or os key documents and they say go through something like I don't know if you ever heard the acronym jam Threads, whereas go through all the different systems when you're doing history. But the reality is when you've got eight minutes. If that's what it still is in Kings, you got eight minutes through your history, six minutes to actually do the history with two minutes to present and questions. You don't have that much time. So you've got to be quite succinct in your history taking and relating it back to our skis. Uh The bulk of your, our history will come purely from that presenting complaint and history presenting complaint. If you're spending for, you should be spending about a good four of your minutes on that part because that's going to be all of the new and good information following that. The rest of the questions that you're gonna be asking, uh I can even just for your benefit, I can try to show you a little bit. Uh I know I don't have uh someone next to me to go through a history with you. But if it was me asking these questions except barring present to complain, a history presenting complaint, which I'll go through with you and the systems review it a little bit more detail for this power point for the remainder of those questions. It personally takes me, I do this daily at work and it takes me about a minute to rattle through and this is why I would, how I do it. I would just say, do you have any other medical problems? Are there any of this for this uh past medical history on words? Do you have any other medical problems. Do you have any reason to see the G P? Are there any reasons you've been to the hospital recently? Do you take any regular medications? Do you have any allergies? Uh, do you have any conditions that run within family? Uh, you don't want me asking who do you live with at home? Do you work at the moment? Okay. And again, a few questions I just have to ask. Do you smoke? Do you drink? Do you take any recreational drugs? And have you been traveling recently? That's, it just gives you my point of saying this to you is just, it gives you an idea that that say that last part of questioning can be rattled off fairly quickly. So the bulk of your Rosky history taking comes from that beginning part, the first part of your presenting complaint where you always ask open question starting with what's the problem was brought you in today? What's, uh, what's happening soon? Something open and they'll tell you straight away that something's hurting most likely, that's what orthopedics will most likely be like. And then the, the meat of your history is on history presenting complaint and the, and a bit of extra questioning around that complaint. So we'll go back to the chat if this was a patient. Imagine you're stood in front of that daunting or ski scenario in the stations there, the buzz is about to go off. And so, and you read a bit with vignette and it just says that you, you have been asked as the fourth year medical student on the wards to take a history from a 50 year old male who is complaining of right knee pain. What kind of questions are you thinking of? So you've got the rest of those normal questions that I rattled off a second ago. But what special questions are you thinking of in your head? that you might want to ask this chat by all means guys, that by all mean, I'll if put in the chat, answer the questions more interactive is the barriers for me, barriers for you guys as well. And Socrates bingo, very good. That's, that's one of the key things you want to do. So Socrates and I'll be going through that in a bit more detail. Now, if I'm, if I'm holding in a bit more, because I'll tell you the answers in a little while, I want to get your opinion guys. If so, if you're thinking of knee pain straight away, you go through Socrates. Is there any other questions that come to your mind? Anything that's associated symptoms think about that might be, you might be thinking about in terms of you've done the Socrates. But you know, in the a in the Socrates, it says what extra symptoms. Now, it's always a cheat when you turn around to the patient and say, do you have any of the symptoms? And they say, I don't know. Doc, you tell me so, anything else property your mind. If not, it's okay. I'm not gonna all right. So a few things that are more that you're thinking a little bit more orthopedically with pain, a few of these things. So, yes, you want to be grilling the person for the exact mechanism of the injury, pain and for that you'll be doing your Socrates. But a few things that Socrates might not catch, but when you make your history go from very a good history to an excellent history. When you're thinking about pain, especially in the orthopedic sense and someone's gone through recent trauma or this, they've come to your knee pain, you can start to think about. Is it stiff for you? Is it been swollen? Is it unstable? Does it look deformed? Have you, is it affecting your day to day function? Do you have a limp? Is it, is it affecting your gait? And then thinking a little bit beyond that into the neurovascular side? Is there any effects to your sensation or weakness as well? So as you can tell these, these are my set of questions that I would be thinking about for the joint pains which might present as part of one of your history takings in your Rosky. It imagine this little set of questioning as though the same that you would have if it was like if I told you a chest pain and if you walk in with the chest pain, you'd be asking some cardiovascular system of your questions, which are things like. Okay. Do you have syncope? Do you have shortness of breath? Have you got a cough? Have you got any edema of your legs or your sacrum? Have you had any palpitations recently? Is that kind of questioning? But I'm trying to related that whenever you're going to these, uh, ski or history taking stations, you want to be going in there with a few little bullet points in your head because these, if you don't remember all of them, but if you start asking a little bit about, oh, is it stiff for you? Is it, do you feel like it's swollen? Do you ever feel like it gives way instantly if you're the examiners sat there marking you because this is more, the reason of my talk is more based on orthopedics. Uh They'll start to be like this guy knows what this person knows what he's talking about. He's actually been asking beyond just the Socrates, which I think everyone kind of knows what Socrates is. But the reason I'm here is to give you that little bit of extra uh extra embellishment onto your history taking examinations. So then you've, you feel a little bit better and let's be honest, to get a better mark in the end as well. So jumping into a little bit more in detail on those different points for, for orthopedic histories or better yet for any trauma history. If someone, if you get any Oscar station for history taking and they've said someone's had an accident, someone's had a fall, someone's hurt themselves, they're coming with pain. It is your responsibility to find out the exact mechanism of the injury. And by when I say that you need to, you need to clearly have a good strong image like a video in your head of exactly what has happened in that instance. He's just a bit of an example, but you need to know how it's happened when it's happened where it happened. If there's a car involved, how fast the car was going, how, what, what was the car like or the building like or whatever they struck into? Were they ejected from the car? How were they found at the scene? Were there any body parts that we took the first impact? Uh Yes, I've so I wrote it here. This is more in practice rather than your of skis. But if someone's got a video even better, if you got photographs even better, you probably won't get that in your active stations as 3rd and 4th years. But it's just what you don't want is to get a very basic history of someone took comes into you and start saying, oh my, uh my, my knees hurting. Uh I had a car accident and you say okay. Uh I'd rather and say, and then you just jump into Socrates straight away and start saying, where is to jump into Socrates? I think it's better for you to ask a few more questions saying okay, you had a car accident. How did you hit the car? What car are you driving? How fast were you going? What did you get into? It instantly makes again, it's another one of those things that will make you go from someone who is just read a text book and just knows that right. I'm gonna go into default mode and I'm going to start doing uh my Socrates on pain and that's what the basic and every medical student will be used to versus someone who's actually listening to the patient. And he's thinking about, he just told me he had a car accident. I better ask some more questions about this. And then as you can, as you mentioned, ready Socrates is very important. If you don't get your Socrates in, you probably won't get the marks either. So like I said, it can be a bit of a time, a timely thing as well, but the examiners are very good pushing you along and trust me, you will get more marks, getting a lot more of your questioning in the history presenting complaint. Then if your worst case scenario, if you happen to miss out on just finding out a little bit about family history, and usually they do make their history stations in a way that the person won't have tons of cancer history, something like that from the family side. If they've already got a lot you talked about in the history presenting complaint. So they usually are quite good at trying to balance it out for you. They're not going to have like tons of medical conditions for you to be aware of tons of drug history to go through as well. They'll try to make it so that if there's a lot of history presenting complaint, then the other parts are kind of like, yep, know, fairly fit in. Well, otherwise I've got barely know analogies. My family is all okay. So, but the meat of your history taking does come from that history presenting complaint. I know I'm stressing it a fair bit, but that's the point of this present, this talk, the fact that you're all here at six o'clock, I think it's, and like I said, you're all 3rd and 4th years. I'm trying my best to relate it to how I felt as a 3rd and 4th year and the things that I'd like to take away from listening to a presentation like this. So going through Socrates fairly quickly is quite self explanatory. And I think you can, one of all got used to it probably in your day to day practice when you get, when you're doing your own Oscar training or going into clinics and the clinics in the hospital. But it is a site where is where is the pain? When did it start? What's the type of pain that you're feeling? Where is it going to associate symptoms? Go back to those things that was mentioning before hunting. Are they going through a few of them again in the next few slides? Uh, finding that timing wise? Is it chronic problem? Does it flare up at certain hours of the day? Is it morning or night? Uh, has it been getting better or worse throughout this time? Uh Has it, have you received any treatment for it recently? Anything that makes it better? Anything makes it worse? And then always a 10 out of 10 score. How about how bad is the pain? So Socrates very helpful and following on from that, then this is me targeting those questions in terms of those little systems, review questions. Uh Likelihood is you'll only remember a couple of these, but a couple is better than someone who knows who's not thinking of any of them. So if you're starting to think about, is it swollen, then, then you should always just be listening in the, you're in an austere situation, it's easier said than done because you're quite nervous. But if someone's thinking about swelling, then just think to yourself, what you want to know about it is how swollen is it? When did the swelling start has been getting bigger and bigger? Is it painful? Say with instability, when did, how is it giving way all the time. Is it giving way only, uh, is it given way in a certain position? Deformed? Have you had any previous operations? Limping you using anything to help you with the Olympic? Like a walking aid? How long has it been? How long have you been having this limping for? And it's the same way if you think about it as well. I'm trying to pain was the easiest history I could give you. But imagine now if someone, if the history was changed a little bit and it said a 50 year old male, please take a history of 50 year old male that's come in with longstanding swelling of the knee. I imagine that might panic you on a little bit more so, but it's the same concept. You'll still use your Socrates, you could still use those same questioning. Whereas this time you'll talk a bit about you ask about his pain. You'll still try to find out if you had any injury you can ask about if he's unstable, limping. This system review works. It always that depending doesn't matter what sort of complaint they present with the actual presenting complaint. Your systems review could encompass all of these different little, uh, signs and symptoms as part of it as part of a thorough orthopedic history. If, by the way, guys, if I'm not making sense, I'm going a bit too fast. Uh You want to clarify anything in a bit more detail, then please uh, fire away in the, in the chat. Uh, if not, I'll just carry on, uh, loss of function is going on again with these points, uh, effect on daily life. Uh, talking a bit more about if they're, if they're a sporty person, sometimes if you think about trauma and injuries, if you're a football player, if they, they do some rugby or something like that, then is it affecting their sports? Uh, is it affecting their work? Is it affecting your day to day activities? Uh And in terms of orthopedics and red flags, something's two things that are here that will be in nearly every history that you take. I think these just good questions. These are called constitutional symptoms. Is your red flag symptoms because let's be honest when you're Noski and you're doing a history of someone saying to you that this is going, this is me pushing away from orthopedics. But if this one starts telling you that, please take the history of a patient who's, who's got a fever and started vomiting, please take a history of a patient who's got abdominal pain asking about weight loss, asking about fever. They are very important things and if any of them come up positive, you, there you go, you've got a differential as well because you can always then say, uh I think this person might have cancer as a possible differential, both peaks in particular loss of sensation or motor function student incontinence. Uh these problems in particular, uh I was trying to hint a bit more towards a cord require kind of picture of someone saying they got back pain. That's a classic one to think about, which is a serious problem. Uh, I don't know if many you come across quarter require that much, but I'll just mention it a little bit, but it's, uh, it's a compression of this, uh compression of the nerves in the lower end of the spine. It's got a golden hour because they're those nerves in particular supply the uh supplies the pudendal nerve in particular, which is for bowel and urinary incontinence and also perianal sensation. So, if someone saying they've lost, they've got incontinence and they've got uh loss of sensation in that area to start to have that in the back of your mind as well. But weight loss and fever, if you start, if you should be incorporating that in most of your, uh, weight loss fever, have you had any recent infections? Tiredness is an interesting one. I didn't put it here because whenever you ask any patient out there, are you feeling tired? I'm sure every single one of you sat in this room right now is probably saying, yeah, quite tired. So, uh, tiredness is a tough one because everyone comes out with saying, yeah, I'm quite tired, but weight loss is a good defining marker. But recurrent infections, they're having the fevers. It's something to think about that there are immunocompromised and that could increase the risk of cancer being a possible differential in them. Now, this is me just going, this is me more for completeness for orthopedic history taking but something not for, not to worry yourself about for the for when you're doing your own skis prepared and forth here. But for completely, I said this presentation, I just went through some basic risk factors that should be triggering in your mind. Maybe when you're thinking of the patient in front of you, when you're taking a history for orthopedics. So for me, age is a very important thing. Children have uh more flexible bones, elderly have brittle bones and osteoporotic, uh male and females or females more inclined to having higher osteoporosis because uh when they enter menopause, then they lose their, then have reduced estrogen ish. Did you improvise bone protection? Obesity is going with? I believe it is good. It's actually no obesity, obesity can increase the risk of having poor bone healing. But it's actually malnutrition and someone who comes in underweight that is a higher risk of osteoporosis, lack of physical activity, the drivers enough vitamin D in the diet, they're smokers if you should ask about this, their occupation and they're sporty person, family history if they want, if you're getting recurrent infections, uh S C A was referring to spinal cord atrophy. I don't know why. But uh if you're having, if there are other medications, steroids which are thinning the bones, alcohol thins the bones as well cause increased osteoporosis. Uh If there any previous injuries, if finding previous cancers, these things, just a little triggering factors in your mind, start to make you think if someone's coming in old frail alcoholic having multiple falls, then you your mind starting to think. Getting it just helps to create that picture in your mind that this person is coming with some brittle bones increases the risk of fractures happening for them. Good. So that was my bit bit on history taking in the context of orthopedic concerns and M and M S K kind of histories to summarize it. I know it was a fair bit to go through. But the takeaway I'd like to you to have from the history. Part of this power point is if I go back to that first slide, this one here, this is the key one here for you. If you uh if you think if someone's coming in with a problem and you can interchange any one of these, these symptoms for the main presenting complaint, I've wrote a 50 50 year old male with right knee pain. It could have been a 50 year old male with saying he's got right knee swelling, he's got hip stiffness, he's got him. Instability is coming in with a limp. Your questioning should be, yes, you get your Socrates out the way, but you should be trying to think in your head when you're in that two minutes waiting before you go into the station. Okay. Why do I ask about? I should be thinking about stiffness, swelling, instability, a limp. If you have a few of them, not all of them, even if you have a few of them, like committed to your memory. And you've got, you know, there's going to be an M S K history to tackle, you will come out looking so much better because most people just do the Socrates, but you'll have a few little extra fluid precious to add onto your history. That will make you go from a good history to a great history. Okay. Now, let's try to go through some M S K exams. So M S K exams, they sometimes seem more difficult than they are, but reality is they are broken down into form main steps. And if you struggle, just go back to, if you've done, if you're doing these more steps, look at the, so with any, these are gonna, we'll be mostly joint, that's what MSG exams are. So, look at the joint to start with, have a feel of it. So palpate it, move it uh, in the ways that it can possibly move. And lastly, there will be some special tests at the end of it as well. If you can do that much, if you start to struggle and think great. I don't, I forgot the next steps in my exam just literally think of look, feel, move. And if you're very clever, you might get some special, you might remember a little special test at the end of the exam and then that will help to increase your marks. So we'll start off with the spine exam. So looking at the the look portion portion of the exam, the first part is always you'll start for your exam. You'll start off with uh you're washing your hands, introducing yourself to the patient, getting the patient's consent, exposing the patient properly, explaining the procedure to them, what you're gonna do for them uh That you'll get used to regardless. Uh After you've done all that, you'll go on to the first look. The first look is a basic look, always standing from a bit far further away and you're gonna just look at the patient. This is gonna be the same for every exam that I go through. So it's gonna be copied and pasted pretty much in all these slides. But that look part, general inspection, things that you're looking for. Look at body have meters check if there's any obvious scars, any muscle wasting classically classically, if you, you're looking for ox ski histories, look around for two seconds cause I guarantee you they will have put their a wheelchair or walking it on purpose, especially if you're 1/4 year medical student. They love to do it. I remember in my time they put one just in the corner he had a, we had a walking stick and people just forget we'll just have a quick peak because that means that he's according to walk because think about the people that are bringing in for your Oscar history, there's not gonna be someone with an acute open fracture of his bones sticking out. He's going to be in any. They can only bring in people who have got, uh they want to bring people who've got signs. So then you can do a positive findings in your examination. So what we're gonna do is when people who've had previous injuries and scars, so be on the lookout for them. Now, going back to spine this now when he goes to close inspection, you're just still looking, you haven't yet put hands on the patient and you be obvious with, with your examinations don't go to the point. So people might think, say things differently to you. Now, I found something that was very tough for my examinations and it took me a while to get out with the rhythm of it, but I felt it helped me tons when I uh and this is how I got better marks when I did my house keys. And it's, for example, I'm asking for when I'm doing a close inspection, I've said here that you're going to be looking at a person's front. Um then you want to turn him to turn them 90 degrees, look at them from the side turn nine degrees more. Look from the back, then turn another night degrees. Look on the other side. Now you can be that person. You can start start saying okay. I'm, I'm just talking to my examiner throughout this examination. Uh First of all, and then you can start rattling off uh so many things and be like, okay. So I'm just telling you the examiner, I'm looking for, I'm looking at the posture of the patient. I'm looking for any cervical lordosis, thoracic kyphosis, uh looking for lumbar lordosis. I'm looking at spinal alignment, looking for if the patient's scoliosis, scoliosis, I'm looking at the spinal crest, I'm looking for spine. Do you see that is just, it sounds like verbal diarrhea, in my opinion, it sounds like you're going through so much, so fast. You're panicking yourself. You don't come across looking very calm, cool, collected and I say this for every exam that you do as well. Now you'll be there thinking maybe that. How does the examiner know that I, you're, you're trying to show off your knowledge to the examiner. How does he know that I'm going through in my mind. I'm thinking about all these things. The examiner wants to see a slick nice relaxed examination. He's taking off the boxes as you're going along. So the better way to do this would be okay, sir, if you don't mind. Uh just standing in front, I'm just going to take some time just going to have a look? Ok. I'm looking at the front. Do you mind is turning to your side for me? Do you mind is turning to you back uh to the other side as well? Now, when you present this patient at the end of your examination, because that's what the whiskey examiner will ask. You say, can you present your findings? That's when you can say when I was looking at the patient, I couldn't, I noticed no spinal deformities, no, no deformities in the alignment of the spine. Or if you're really being clever, you could say it's not like I noticed that I didn't notice any scoliosis or lordosis or any spinal deformities on looking at the patient. That's all they want. Um The, the reason I say this is because I remember when I remember when I used to do not just M S K exams but for cardiovascular or abdominal exams. And this is just, uh this is my opinion but going through someone's hands and you're going through them and saying, I'm looking for Osler's nodes and january lesions and splinter hemorrhages. I'm looking for Dupuytren's contracture. It just comes across as imagine just picture yourself as the patient and imagine you're at the G P with your own doctor. If you said you've got a problem with your hands or you're doing a cardiovascular exam on you or he's doing one on you? Do you think they're gonna be rattling off so many things. No, they're just gonna be talking to you casually and that's much nicer approach to the patient than you just bombarding them and bombarding them with tons and tons of information. I hope that makes it a bit of sense. That's my personal to sense on a ski examinations and it fared well for me and it made me become a lot more relaxed when I took, when I examine the patient. Uh, and I hope you find you have some use to yourselves if you start using in your own practice. So kind of a dwelled a lot on there. But moving on from that with a spine exam, the next thing to do is check the gate again, a very quick part of the exam. So you've looked at them now, just ask them, just say if you don't mind, sir or madam, do you, do you just mind walking a few steps for me and now just walk a few steps backwards and all you're doing is just assessing the gate again. You're not saying all these hundreds of things, you know, I'm going to start saying I'm looking at your gait cycle. I'm looking at the limb length, I'm looking, I'm looking at your turning and you, if you are waddling gait, you're just looking, you're just looking at them. It's just part of the exam and that sort of a tick box saying that okay, good. Please check the gate as well. Next you go to the field part spine. Very nice and easy. You'll be feeling the back of the back of the patient because that's where the spine is. You'll go down the spinal processes, you'll finish off with the sacred iliac joint. So I'll palpate those a little bit and then it's the paraspinal muscles. So, just go feeling just approximately 3 to 4 centimeters from the spinal process and that's just the muscles around the spine. If they've got any spasms of pain around there. Nice and easy. Now you're getting to the movement part if you're struggling or movement for any of these M S K exams genuinely have to think to yourself. How does that, that joint move? I honestly think about it. Sometimes when I'm doing an exam, I sit there and I think okay if I'm doing it, hip exam or a shoulder exam or an elbow exam, what natural ways can this thing move? And I sometimes even start moving my own head a little bit. So for it's one c spine, you can flex it, you can extend it and you can do lateral flexion, flexion and always the first thing to do is you would always want to do a passive movement first. Then active movement, no, my apologies. Sorry. I think so, active movement first, then passive active movements, that means ask the patient to do the movement. So you can either tell them and say copy my movements and you can then flex your neck and watch them do theirs and then get them to extend and then uh lateral flexion. So that's bringing the ear to the shoulder. And then after that is when you'll say okay. Now please, if you don't mind, I don't mind, allow me to move the neck and then you'll, you'll start to move it because sometimes they might have a bit more, they might be able to move it a bit more that joint, but they're a bit hesitant to do so. And that's when you actually moving, it allows you to see the full range of movement. So the C spine, that's the three movements you'll have. But the thoracic spine, very simple one. The only thing it can do is rotate and it can only rotate slightly. I'm talking about 10 to 15 degrees or maybe 10 to 20. And that's when you'll put us the patient to cross their arms across the chest and then usually sitting down. So they're not getting the lumber twist, but just then you're just isolating the thoracic spine and then you're able to ask them to twist. And next, I just realized actually hurt. Can you see me doing any of these movements? Maybe? Yeah. So you put the hands across the chest and just asking them to move like this uh for the C spine is flexion going down, extension, going back up lateral flexion to the side to the side. And then a lump of spine is flexing to the toes. So you're bending down, how can you touch your toes extending? So, going backwards and then lateral flexion as well. And that's bringing your arms as far down as you can to one side and as far down as you can to the other side, that's the movement part of the exam. And then this is the clever part if you think you're really good and you can remember a few of the special tests here there. Yeah, one's called Schober's test and it looks for enclosing spondylitis. And what you do is you start off by identifying uh the posterior superior iliac spines. So essentially, it's the boat. Now, can I actually can someone to shout out? Can you see me move my mouth on these slides or not or do I have to use? Like is there like an actual laser or something or because someone just mentioned it? Uh Yeah, I can see around you can see them. All right. Cool. So if you, so for instance, your mysteriously expired posterior superior iliac spine is approximately hereish and hereish. And you'll just feel for uh if you feel a bit of bumpy nodule there, not a nodule, but you'll feel a little bit of a hard point. That's your peace P S I S and imagine, then you create an imaginary line towards the center. You put your first cross in the middle and then you will need a tape measure and you'll have to go 10 centimeters open. But the next cross and five centimeters below that way, you've got 15 centimeter line between those two upper and lower points, that's 15 centimeters. Now, you ask the person can you bend and try to touch your toes and that should have increased uh to at least 20 centimeters if it's not, that shows you that that lumber spine is a bit more fused than normal. And therefore those uh those vertebra aren't able to move as freely, aren't able to flex as much. And that is an indication of an closing spondylitis. Do the test for spines know the special test is a sciatic nerve stretch test. That's what the patient supine. As you can see in this image over here, all you're asking for them to do is you're gonna make them stretch the leg. You can, you'll be the one holding this and push, pulling it all the way up as this patient is on the diagram. And then you'll also ask them, you'll also get them to start to Dorsey flexing the foot if that starts to cause a sharp pain because you're stretching the sciatic nerve. That's another test to say that oh, this patient might have sciatica or sciatic impingement. Too simple text to finish off your spinal exam. And as always, you're gonna say to complete my exam, I would like to have done the upper. I would like to do a neurovascular examination of the upper and lower limbs. Always. So do the neuro neuro exams. And then you're gonna do the joint too, both in the joint and below. In this case, the show the spine is a bit weird, but you can say the shoulder and you can say the hip because they're both kind of in the similar region. And then I would do some further images if needed. I hope that all made a fair bit of sense and now I can move on to the hip exam again. Fire away guys if there's any questions on your end, if you find it, if uh you have one to clarify anything, any minutia about spine exam, uh more than welcome to. Otherwise, we'll crack on and get through the hip, examine a few others as well. Uh So we can just run through these M S K exams for you. So, hip exam again, same thing I did say I was a copy and paste. The first little part of the slide. Go to the start of your exam by looking at the patient, look out for those walking aids and wheelchairs. Next, you're going to look at them again. But you know, you're looking closely at the hip, usually can get the patient to stand for this and you can get them to just look at it anteriorly. These are a few things you might be looking at. Are there any scars any bruising, any wasting of the quads, any change, any straightaway overtly, any leg length discrepancies? Can you notice straightaway a pelvic tilt after that, turn them to the side? Is there any, does anything look a bit odd that it's not looking like a straight normal leg? And after that, turn them to the back, any scars, any muscle wasting of the, the gluteal or the buttock region, in terms of, in terms of exposing the patient, you'll be doing it for your initial part of the exam when you ask them to please, if you don't mind, could you uh could you remove your bottoms for me? Uh That's probably the best thing I think for hip exam, uh you'll need to have that much exposed at least. So they should be wearing some sort of undergarments underneath. And if you really want to, if, if you really feel necessary or you want to increase the market, you say that my my examiner will be acting as a chaperone for the examination for this examination. Is that okay with you? He'll probably say yes cause he knows that he or she, they know that they're going to be examined today. So uh if you're, if you're feeling a bit worried about exposing the patient again, gate, same slide, hip, same as spying, need to just ask them to, to walk and uh you'll notice straight away if it's a waddling gait. If there's a, if there's something wrong with it, if they get, if they're, uh, they're, they're stepping wrong. If they've got a limp, you don't need to genuinely, I don't think you need to know all the ins and outs of, uh, of the different types of gates. There's, there's like a high foot gator, high stepping gate, a waddling gait. Uh, uh, there's one way, there's a circum circumduction of the foot going across. If you can know it's normal from abnormal, the examiner will be happy if they have an abnormal gait. If you can end up saying that they've got a bit of a limp. Uh When you present the patient at the end, they'll be happy with that. Following are painting the hips. So at this time, you've got the patient lying on the bed part, patient check for the temperature and tenderness. So usually using the back of your hand, just have a feel of the joint itself, feel for the greater trochanter, which is on the lateral aspect of the hip. And that you can sometimes tell for trochanteric bursitis. Then it comes to these leg lengths when you're measuring a true leg length. I'll be honest with you. When it comes to the actual examination, probably no one will give you a measuring tape. If it's kings, they probably won't. And you can just sound good and say, ideally at this point, if I had a measuring tape, I would like to measure the, the leg lengths of this patient. And they'll say Yeah. Ok. Nice. Carry on. But if you, if, if something changes and they have given it, if they have actually given you a tape measure, then you could, the way it's done as you're measuring from the uh anterior superior iliac spine and that's going to the medial malleolus. And uh apparent leg length depends. It is from the umbilicus and that's to the medial malleolus. And uh you'll compare those two lengths. They should ideally, uh they should ideally be the same on both sides for both lengths. If not, then that's a discrepancy or one might be bigger than the other. And that's indicating that the pelvis is tilted slightly in one direction. Next, as I said, you look, feel move. So start to think to yourself, how does the hip joint move? It is a good joint because it has pretty much quite a lot of range of movement is that ball and socket can go pretty much quite 3 60 degrees. So you can flex the hip and extend the hip. So the way I've broken this down, actually, uh I think it's nice if the patient's already lying down or if they are, you can get them to stand up if they've got the ability to and then you can say, okay, why don't you flex and extend the hip to start with? So hopefully, this diagram on the side just quickly shows you the type of movements that you're looking at flexion is coming forward, extensions going backwards. You, that's all that you get them to do when they're standing. Then you say, all right. Now, why don't you lie down for me? And at that point, you can say you're gonna struggle to extend the hip when the lying on the bed. That's why I'm not wrote it there, but you can get them to them to flex the hip. And again, as always, I wrote at the top of the slide, always active movement first and passive, get them to do the movement first, then you do the next. Then you say right, can you allow me to do the movement next? So flex the hip, then internal and external rotate the hip. So that's essentially getting into flex position. So with the with the hip, John bent and then you can grab uh the ankle or the lower leg and you can start to twist that outwards. No, I'm just trying to see because I can't see myself book. You can essentially then try to twist it outwards and inwards. That's your extension and that's your internal rotation and external rotation and adduction and abduction is essentially get them to, can you bring your leg outwards and then to test that against passively, you can do it or you can try to put a bit of pressure against it as well to see if they can do it against resistance. And if you really wanted to ask on the bed you can get them to do hip extent. And that's when you ask them to turn over onto the bed and then you can test it passively, you can fully then get them to extend the hip. But you actually physically grabbing, they're telling them to extend it as much as the cancer that's trying to essentially get their heel to touch their bottom and that's extending the hip. And then you can actually take the leg and try to bend it as much back as you can. That is the movement part of the exam. So as you can see, we've covered quite a bit there, there's a few different movements for the hip to be wary of. But genuinely, if you're struggling a little bit, just start to think to your own self. Uh The commons pears I find as well. So the hip flex and extend internal rotation, external rotation, abduction adduction, there's three pairs of movements and just commit them to memory a little bit. Hence, some people call this a try plainer joint as well for those three axis of movement. And then for the hip, some of your special tests, one is called Thomas test as you can see in the top image there. So you put your hand below the patient below their lumbar lordosis. So there's usually a bit of a gap there and that's what you possibly will flex the hip as that as he's doing in that diagram. And if the opposite thigh begins to rise off the bed. Then you can think, then you might have a fixed flexion deformity of that hip because it's kind of connected to it. And therefore you flexing the one hip is causing you flexing his right hip. In this picture is good, it's called, is connected and causing his other hip to flex as well. Trendelenburg test, it refers to the hip abductor, so your hip abductors, so the short external rotators of the hip, they're week. So you get the patient to face, you get them to put their hands on your shoulder for stability and then with your fingers, your whole, you'll be feeling that A S I S. So that's the body part in the lateral part. So that's just feeling the, it's the top of the uh it's the top of the hip. Uh you'll be putting your hands there and then you'll ask them to stand on one leg if you find that your hands and instantly drop. So that means it's a pelvic tilt, that means one side and of them has week abductor's, that's the special tests to finish your exam, neurovascular examination of the law, all in the joint, but broken below. So the spine and the knee and then further imaging if needed, right. We'll carry on. There are a few more. I hope used to look for it guys that I have not tired you out going through the examinations. Unfortunately, I couldn't really interact them as much as I wanted to. But I felt like maybe it's just nice for you to, for someone to go through all these examinations with you of what is expected. Because sometimes you see different online. I feel like there's a lot of discrepancy when you start going online for certain things. And you think is this vitally important for the exam? If I don't do this in the exam is you're gonna make me fail. Usually, if you're looking at that point, it's probably just a little minutia, little discrepancies. But hopefully by me going through a few of these joint exams for you and then maybe you can look at them in your own time. And if, if you watch the road recording of this lecture slash, you look at the slides, then you'll be able to jog your memory quickly and it's a quick, easy resource for you to go to. Okay. So I'm just gonna crack on and hopefully we'll go through this a bit quicker pace, knee exam. Same things start by looking at them uh straight on. Uh look at the materially lateral. So again, you got the, the knees exposed this time when you look at the materially scars, bruising, swelling, look at the patellar in particular, is it a valgus knee or a various knee? So the the board legs or the knock knees, some what I call them. Can you is any wasting of the muscle look at them laterally again. Does it, is it looking straight or is it looking bent in any way? Look at the back of them and then his scars, any muscle wasting any particular swellings in the Popliteal region gait again. Is your local um exams get him to walk a few steps, walk back. It shows a lot within a few steps you'll know. Is there a problem in his knees? It buckling, is it causing him instability discomfort? A lot of bosque actors, a lot of bosque patient's or actors, they like to go over the top. So you'll find someone, maybe you ask him to walk and he just starts to randomly buckling one of his knees. There's your, there's your findings and then when it comes to palpating, there's a few more things for the knee. Always back of the hand people, the temperature you can look for quad wasting. This is me being particular. If you're, you can potentially get a tape measure measure on the pods on each side and see if it's the same, then you can uh with the knee extended. So that's where they're fully stretched out. You can feel for the patellar. Uh you can feel the medial and natural joint lines and then with the knee flexed, you can then feel for the patella again because now you've opened up a few more of the structures with the knee flexed at this point and you can then feel again, for those medial and lateral joint lines, the tibial tuberosity you feel for the head of the fibula and also the back of the knee as well. Because now you've bent the knee, you can actually put your hand behind it and it's not so tight anymore. It's a bit more softer to palpate the popular teal bossa, the two tests are put here, which are a bit different because you would have done this anyways, you would've been feeling the knee where if you bent it, feel, feel it when you stretch, extend it because that's the only things that you can do really, it could do a few more things where mainly it's a hinge joint at the end of the day, two things, the patella tap and sweep test. The, these two tests are looking if there's any a fusion in the knee or swelling in the knee patella to is kind of what this image is showing here and it's effectively you squeezing and trying to just milk the top of milk, the femur going down to the knee and then you're gonna feel the tip of the top of the patella and see if there's any swelling that's there. Now. And the other thing is called a sleep test where you'll slowly start to move the fluid around the knee if it's there and uh that you can move it around a circular motion from the bottom of the knee to the top. And if it's collect in one location that, that is showing there's a, that shows us fluid around that knee area that's not deep in the joint. It's rather swelling, that's superficial. Again, active first, then passive, get the patient to flex, flex. It's just flexion extension. You're not doing any of the movements really here. Flex tell them to, can you bend the knee then stretch, then straighten it, then you get the, then you bend it and straighten it as well. To be honest, I like this positioning as well. People in the patient prone on a bed in this situation sometimes better because if their knees hanging off or ideally do it with the knee hanging off because then you can get the full range of flexion extension in one go and special tests. The knee has a few more than others. You might, I don't think for four, third and fourth year Oscar examination. If you even start to think of any, a few of these great don't get so drawn down that you need to think of loads of them. ACL and PCL important tests. So anterior draws and Lachman's test. So essentially, it's putting your hands on to the knee joint and just trying to give it a force forwards and backwards to see if it's got if the ACL PCL disrupted lateral and collateral ligaments uh that's been shown by the images on the side. So not the, not the gifts but the, the images that you're just trying to bring the knee, you're trying to stress the lateral side and then put some pressure against it, stress the medial side, put some pressure against it sometimes. This is, this is how my brain works sometimes. But I always get confused between what's, what's uh testing, what? So various stress test. So Vargas has six letters in it. Medial has six letters in it. That's how I remember valgus stress test in the medial. That's it. That is stretching the medial collateral ligament a weird way. I know, but maybe it helps someone, someone of you as well, then you can also check. This is being again, I think if you're thinking of the first four tests, fantastic. The next two are really, really specialist. I would really, I, I genuinely won't, I don't think you need to know them as well, but it's the called mcmurray's test and he's testing for external rotation, uh his medial whiskers and lateral meniscus. And uh I think if they're moving on your side as well, but essentially, is this test here that this gentleman trying to do you can look at in your own time. We're not gonna go too much into detail with them since I've got a few more tests, exams to go through. But essentially this is where he's doing. He's just trying to uh he's got it flex and he's extending the knee and then he's also twisting it into external or taking the foot or internal taking the foot and that and then if the patient saying that it's locking or catching or, or it's unstable, that's referring to a minister, physical injury. As always finish the exam, uh check the New Russell stairs, then say I'll look at the hip and the ankle and any further imaging for an uncle exam start by looking, there's always been a close inspection of the foot and the ankle look for scar. So again, you can see always be obvious. Say I'm looking at, I'm just gonna at the front of your foot. Can you turn to the side and look in the side of your foot, turn around to the back just to look at the back of your foot exam in Australia where that you're, you've done a thorough look of this patient. Uh and therefore he's giving you full takes that. Yep, he's done his job. He's looked at the whole joint in all angles. Again, you're looking at scars, bruising, swelling in particular for the foot. This diagram over here, I've tried to show for you little things that again, think of what patients' can present to you for a Noski people with these longstanding problems like a hammertoe, a clot or a mallet toe looking at the arch is, is very important. Have they got a high arch, a low arch again, gate for local um exams then pop it, temperature is important. Ulcers are important for foot. So posterior tibial pulse is just behind the medial malleolus to shorten the first image and then your dorsalis pedis polls is more uh that image is a bit too high for me. Maybe it's a little bit more towards the middle, just varies. If you can see my, where my miles is pointing and that's where you can feel the dorsalis pedis polls. Next, you can also squeeze all those metatarsal political joints. If if you can hear a mood, let's click. Uh that can indicate a Morton's neuroma. Then you start to go in detail. It's kind of like you had an example. Uh you start to palpate each of those bones. So all the bones in the foot and just be very thorough with it, just start to feel all the way up the foot, down the foot, feel all the little bones in the, in the toes. Uh So I've said here, metatarsal the ankle joint, feel the calcaneus, the fibula tibula just be over the top of it all. Just give it everything a good feel to see if there's any hurting, the patient, feel the tendon, the achilles in the back and also have a squeeze of the gastric muscle as well. There you go, you had a good feel of the muscle. So you know, you look, you feel time to move. So the uncle has quite a few different movements you can do. And this diagram here tries to show them for you I thought this was the nicest guy and, um, I could find because I sometimes getting confused plantar flexion. Dorsey flexion. So, uh planters going downwards. So you're only tiptoes Dorsey's going upwards, then you can flex and extend the toes and then you can also invert and evert the ankle. So get them to do it, then you hold the foot and you do it. And in terms of special tests, luckily the ankle and the foot is a nice one. It's only got one. It's called Simmons test. Get them to kneel over on the chair like this, squeeze the squeeze the gastrocnemius muscle which is connected to the achilles and that should cause the ankle to move as well. Then you can complete your examine as previous ones as well. Right. How much more I got, I think I've only got two more hand and wrist and shoulder joints. I know I'm going to the upper limit, but I can see that I am getting close to my timer. Well, I'll try to run through them fairly quickly. So as anything with all exams always start off by just looking around, seeing any scars, wasting any, any aids or splints that they've got, then start having a closer look at the hand. Have a look again. If there's any scars or any previous carpal tunnel surgeries or anything like that, have a look at the color. Is any swellings? Have they got any Heberden of Bouchard's nodes? Have they got any swan neck, NG N E Zed thumbs or Patagonia's deformities? I think I always get confused with them. So that xanthum there and there's also a Patagonia there, which is the P I P J joint. And then that's where that's flexed. And the other one is the swan neck deformity is there's extension of the P I P J and flexion at the D I P J joint. Uh They're rheumatoid arthritic signs, you know, they got psoriasis and they were still into hemorrhages. Have you got any pitting of the nails? Have you got any muscle wasting of the hand again? Look at the palm of the hand and uh before I carry on uh Paul, if you're still there, uh Am I a strict one hour or can uh you can keep going, keep going? Alright, I thought there might be a time when it's off. All right then fair. I'll carry, I can talk a bit on. Okay. Uh So yeah, look palm of the hand. Uh what you're looking for again. You are uh Oh no, sorry. I was uh for the previous one I think. Uh let me just go back a bit. Yeah. Yes, I broke. They're looking down into dorsal surface so you look at the back of the hand to start with and then you can tell them to flip it over and then look at the front of the hand and things you might be looking out for uh the posture of the hand, if there's any of the scars are swelling, if there's any Dupuytren's contracture. So, you know, when the handle clenches in together, uh is there any wasting of the theme remnants or hypothenar eminence? Is uh are there any plaques on the elbow because you can go that far up and January lesion Oswald's nodes, uh I had to actually look this one up. January lesions in the palm and Osler's nodes is on the digits when they both have signs of potential cardiovascular uh disease, in particular infective endocarditis. Again, now you'll start to feel for the hand. So feel for the temperature, check the pulses, radio and owner uh check that he athena and hype athena areas check if there's palmer thickening. So that's referring to the Dupuytren's contracture, check the sensation of the medial ulnar and radial aspects. So, if you remember in your head, the 1st 3.5 digits uh for the median, so you can just have a feel of the thumb or the middle finger. Usually the middle fingers good on her median. Older will be the little finger, radio will be the back of the film. You can squeeze the metacarpal phalangeal joints as you did for imagine. He did the same for the foot. You do the same for here. So all the knuckles, you squeeze them. If it's causing a lot of pain that can be indicating rheumatoid arthritis, then this is the time consuming part of the examination is the by manual joint pile patient. So not if you guys have come across it and I'll try to see myself doing it. So you literally it's hard to do to my own hands, but you're trying to grab it with both. So imagine if someone else, another patient, you're testing it open down and side to side, opened, down side to side, opened down side to side of all the possible joints they have. So that's your metacarpal phalangeal joint. Always, I'll go back to them. Oh, is that what it's like this? Can you still see the presentation? Have I lost it? Uh We can't quite see at the moment around. In fact, give me one moment. Let me show it again. Let me just show the presentation with one time. I don't know. I think you should have gone off. I think it's just gone off. Limited. Share the presentation one more time guys. Alright. Nearly there. I think it's come back on. Just let me go to the slide again. That was on. OK. Dokey Political Chris made. All right. I think we're back. Do you want to see it? Uh Yeah. All good. All right, good. Okay. So yeah, you by manually palpating each of those joints. So you're talking for the metacarpophalangeal, the proximal interphalangeal of discipline to pollen shield. And uh for the film that's also got the carpal metacarpal uh carpal, metacarpal joint. Which is the military is the same as you metacarpal phalangeal joint, but it's the first one as well feel for the stuff, feel for the, the snuffbox. Uh So that's just if you get them to, uh if you get them to essentially uh extend the thumb backwards and you can start to feel into that little anatomical snuffbox area. And uh then you can also start to feel for the wrist as well in general. And just see if you've got any pain. Essentially, all it is is just being thorough when you just palpating. Just think of all the bones and all the potential areas that could have been painful if you've got a system to it even better. And that way you won't miss anything and uh you'll be able to elicit if the patient's got any pain in any of their bones or joints. Next it comes to moving. So I always ask them to do it first and then afterwards you follow up. So you can ask them to start by flexing the fingers. So curl, bending them and then extending them, flex the wrist, extend the wrist. And then you want to test the motor function of each of those nerves. So that could include the radial nerve, which is best tested by extending the fingers or thumbs up. Median nerve is tested by an Oak by asking them to make an okay sign. And then uh older nerve. Some people say it's the lottery ticket or get them to do a scissor with their fingers. After that, you can also test for their grip as well. So, a power. So I think I was meant to write a palmer grip. So if you get them to just squeeze your fingers, so that's the palmer grip, then you got a pincer grip. So that's essentially trying to pick something up with the two with a pinch, like the pins. Uh imagine it like a pincer, the two fingers and to complete the exam, uh special tests for the hand and the wrist are Tinel's and Fallon's tests. Both those uh the median nerve. So it's testing for carpal tunnel syndrome. So one is Tinel's where you'll be tapping on the meat enough and the other one is failing, as you can see in the diagram with the patient's doing it there where you're doing force flexion of the hands backwards. So you're actively trying to compress that couple that carpal tunnel and therefore, that's going to be causing that would then elicit some median nerve symptoms. So that's usually pain and tingling of the median nerve sensation area, completing the exam, you'll do the neurovascular examination of the upper limp. You can examine the elbow and the shoulder and also for any further imaging. And that's the hand examination, hand examinations and for examinations can be tricky in the sense that there's a few more bones to go through. And I believe last but not least guys, I think shoulder exam, hopefully this is the end of all the examinations for possible MSK exams that you will be getting a 3rd and 4th year. But let's go through it shoulder exam. So start off by having a look at the area. Just generally is any scars, any wasting of using any support, then have a close inspection. And again, I'm going back to that start off by looking at a front, on then on the side and on the back. And uh we've gone through a few more points here. But you're looking for a symmetry. Any deltoid wasting any body prominences, any scars from the back, in particular, look at the trapezius, looking for any scoliosis, any winged scapula, then start to pulpit even if you struggling with doing all the little, little parts of the anatomy of the shoulder. I've tried to outline it by this diagram looking. I thought it was a nice diagram for you guys to look back to but start with the clavicle, start with the sternoclavicular joint and work your way outwards, feel along the clavicle itself, then go to the acromioclavicular joint, feel the chromium, the coracoid. So chromium towards the okay to write myself. A chromium is towards the front of the joints. It's anterior maybe that helps you to remember it. A chromium is a anterior coracoid is a bit more further back. Then you go the head of the humerus, the greater greater Gibran City. And uh then you've got the spine of the scapular as well that you can feel. So just be thorough, just go all the way around in a bit of a circle around the whole of that shoulder joint. Next movements. I thought this again was a nice diagram here. This kind of shows you all the movements you need to know for the shoulder and it shows you the way that the move as well. So essentially copy those movements for the patient as well. Best way I sometimes find it is stand in front of them and say, should we do the movements together? Just copy my movement, get you to, then you start doing the flex your shoulder upwards, extend it backwards, abduct. So bring it to outwards adduction, bringing it across your chest. Then for internal and external rotation, you've got to then stabilize it by just stabilizing the elbows, took them in towards the chest and then bring them outwards and inwards. And when you do the passive movements of these, either you could take the joint how to move it in a certain direction or you can do it against resistance as well. Usually I think it's better to just take the joint himself and just say, tell them just relax your joint for me and just grab it and you start to bring it out as much as you can. Special tests for the shoulders. These always confuse a few people. There's a few of them, I think there's four in total. And I've tried to break them down into a slab at each, but this is what they are. So they try to remember one or two of these supraspinatus see testing by this empty can or it's called the jobs test where you started essentially copy the, copy the positioning that this patient's got. So abduct the shoulder 90 degrees, flex it by 30 degrees and then internally rotate and push and get the patient just effectively. Imagine you're gonna empty your can out. That's, that's the image you doing. Imagine you're going to a sink, you're gonna empty the can out and then you're gonna put some pressure going downwards on to it. And that will be testing supraspinatus. You can test it on yourself as well and you will cause a little bit of uh strain on the top of your shoulder. With that test that super spin, it is being stretched. Another one for super Spinatus is the painful arc. So uh I asked them to go put their hand all the way upwards. So maximum reduction and then you start to bring it back down that arc yourself. You start bring it down and down and down. And usually you get this impingement 6200 and 20 degrees. That's when super Spinatus is most activated because deltoid starts to take over from 1 20 to 1 80. If you're getting that, then it's under the indication that potentially they could have had a rotator cuff tear, they could have torn or strained or sprained their supraspinatus muscle. So that's two of the tests for super spinnakers. Now, looking at infraspinatus and teres minor, their function is for external rotation. And uh you contest that via this uh that's external rotation against resistance. I haven't got a photo for that. Uh So don't get confused with the last test That's essentially. So imagine back to that other slide where the patient here is doing the lateral external rotation, you bring it to the side and then all you're doing is you're just giving it extra pressure against it. And that is testing your uh your infraspinatus and your Terry's minor muscles. And the last test was testing soups capillaries is Gerber's liftoff test. Oh Sorry. I just realized that the first images of the external rotation against resistance. The second test is Gerber's lift off and that's essentially it's copying the image that he's just done there. So getting the patient to push them to bend their arm towards the back with a palm, facing outwards and then you're putting your hand against it and asking them to try to lift their hand off of it. And that's then uh testing the subscapularis muscle, right? That's the end of my talk. I think there was a lot to go through there. I wanted to kind of go through a lot of the examination is probably a lot to digest and this is probably one that you can hopefully look back at when you're thinking about when you're thinking about M S K exams. Uh, there are sometimes a bit daunting is a new type of examination.