Musculoskeletal Examinations

Good morning!

I hope we are all well and staying safe wherever we are in the World.

It has been a busy few months for me with tutoring 4th/5th year medical students for their finals/resits (so far, my students have been successful!). Despite it being busy, it has been so amazing working with all the students who bring their own skills and charisma to each session.

Moving forward - for those of you with pending exams, keep working towards the end goal. However long it takes you, which ever exams you have to sit, it doesn’t matter- just get that degree!

Musculoskeletal (MSK) examinations are a great station to have in the OSCE, as they follow the same principles…look, feel and move (and with special tests). The following will be a reminder of the important steps to perform a succinct musculoskeletal examination no matter the area of body. As always, this is not comprehensive, so please read around the subject (i.e. Macleods) for further information.

Introductions

I cannot emphasise how important it is to have a good introduction, as it builds rapport right from the start, and gets the patient/actor (and examiner) on your side. It is difficult building rapport if you have lost it at the start. So - smile, introduce yourself clearly, confirm patients ID and say something nice i.e. ‘nice to meet you” (or whatever suits you). Stand tall and look confident. Ask the patient if they are in any pain before starting the examination (rapport).

1) Look at the end of the bed

Ensure appropriate exposure for joint to be examined. Before even touching the patient or even looking closely, have a general look around the patient, observe the way they are standing/laying. Are they in pain? Do they have a walking stick? Do they have painkillers around them? These general observations gives the examiner the idea that you are not fixated on getting the examination done, but rather that you can think outside the box.

2) Look

Look at the area more closely. In MSK it tends to be similar things you are are looking for i.e. skin changes, swelling, scars (lots of S’s) , deformities (i.e fixed flexion) etc. A suggestion here is to actually look for these changes, don’t just say you will. If you see changes on the skin, say it (even if not MSK related). This shows the examiner that you actually looking and not just reeling off a list.

3) Feel

The ‘feeling’ aspect may vary between areas, but again there are some general principles that apply for most of the MSK exams. These include - temperature, palpation of swelling, bony landmarks, tendons (there may be more!). Tip - before palpating, always ask the patient if they are in any pain. It is all about rapport and being kind to the patient, and NOT causing harm. During examination, you would again ask the patient if they are in any pain (especially if you cannot see their face i.e. spine exam).

4) Move

Active, Passive and Resisted. Nothing else to really say about this one, apart from - practice making it look smooth and synchronised. Doing an MSK examination should flow nicely, and look natural, which can only be achieved by practice.

5) Special tests

Learn them and do them. Each MSK exam has their own unique one, and vary between different checklists - stick to YOUR university checklist.

5) Wrap up

Key ‘wrap ups’ tips:

  • Thank the patient

  • Ask patient to put clothes back on/roll sleeves down

  • Advise the patient that you are now going to summarise to the examiner (please do not summarise to the patient).

  • Summarise to examiner - demographics, key findings (in order of exam).

  • “to complete my examination” - examine the joint above and below and neuro-vascular exam.

  • wash hands.

Well that’s MSK in a nutshell. Keep practising with family/friends, so it becomes second nature.

If you would like any help with OSCE revision, whether it be consultation skills or examination skills, please contact me (link below).

best of luck!

L x

Paediatric History Taking

Good afternoon (or morning depending where you are in the World!)

Praying and hoping that you are all well.

It has been a little while since I have done a blog - so without further ado, lets get to it!

Paediatric history taking has all the same structure that you may be familiar with - we start with history of presenting complaint (SOCRATES vs SQITARPS), then past medical history … etc etc. As with most systems, there are a few additional questions that you will need to take into account. Below is a list, which I will then follow with a little more detail.

*As always stated, this is a reminder and not revision notes (I imagine you have enough notes). Nor is it meant to be detailed (you can sign up for one to one revision for that!).

1) Fluid intake

2) Bowels and urine

3) Rash

4) Fever

5) Up to date with immunisations

6) Antenatal + birth history

7) Developmental milestones

This list is not exhaustive and just to get you thinking.

Fluid intake

It is required that you quantify how much the child usually drinks (bottle or breast) versus how much they are drinking now. Is it more or less than half?

Parents worry about lack of solids (understandably) but from a medical point of view, due to the large surface area of a child- we worry more about fluids, due to risk of dehydration being higher and more detrimental in babies/children.

Bowels and urine

Again, quantify this - how many times are they opening their bowels and how much urine? How many wet nappies have they produced? Are the nappies wet? More or less than half normal? We need numbers!

This is will give us an idea of whether we should be worried about dehydration and also allows us to get an insight into the general wellbeing of the baby - if they are refusing feeds, this may be a red flag.

Rash

This one should be obvious. A rash in a child has to be looked at and palpated. Is it blanching or non blanching? Non blanching being more worrying.

Some rashes are common in benign viral illnesses, some are due to serious viral infections i.e. mumps (see ‘immunisation section’). You should be able to differentiate between a worrying and non worrying rash.

Immunisations

Is the child up to date with their immunisations? You may not be able to recite the whole immunisation schedule, but asking mum or dad whether they are up to date is enough. *Remember there are parents who have decided not to vaccinate their children, so don’t assume.

Antenatal and birth history

A general review of the antenatal history will give an insight into the ‘risk’ of the pregnancy, The way to work this out may be simply to ask the mum whether it was ‘high or low risk’ or ask about the pregnancy generally, i.e. did they see only their GP + midwife, or was the consultant involved to? What were the scans like? Was the mum in and out of hospital? With birth history, was it a vaginai or c/section? (if c/section, was it elective or emergency?).

Developmental milestones

Ask the parent whether they are doing what is expected at their age (taking into account all children do things at different times). Be aware of the red flag cut off age, i.e. walking being 18 months.

Ask if there are any concerns from the health visitor/nursery/school. Collateral history is always valid.

Hope this summary was useful and has given you some tips and tricks for the OSCE (and real life).

If you would like to have any one to one tutoring, please get in touch via email.

Look after yourselves :)

Headaches - the important bits.

Good morning fellow medics,

I hope you are all well and looking after yourselves.

So not long way till the part 2 for CSA in May and part 1 later this year. You got this, just keep working hard.

Today, I am going to give a brief overview of headaches. As I always state - the whole point of this blog is not to teach you new information or make you read long and boring notes…you already have the notes. This is purely a recap of important aspects to remember. It is meant to be a relaxed read.

So read ahead for a fun packed headache summary…

Primary vs secondary

Headaches can be primary or secondary. This is important as secondary tend to be more worrying (i.e. a space occupying lesion). Use questions aimed at ‘red flags’ to help you think of the worrying differentials and also come to the most likely diagnosis.

Take a good history

This sounds obvious, but headaches (and other certain neurological conditions) diagnosis rely heavily on a good history as there may not be much to see on examination i.e. migraines or tension headache. So, get those SOCRATES or SQITARPS questions together and ask away.

Red flags

Rule out those red flags in headaches, ask the important questions- does it wake you up? is it getting worse? Is it worse when you cough/lean forward? Any red flag should get you thinking about a sinister cause of a headache.

Common headaches

There are a few common headaches which are: migraines, tension headache and sinusitis. There are a few uncommon but very important ones: SAH, SOL, GCA. This list is not exhaustive, but have a general understanding of each of them to be able to differentiate between them confidently.

Typical presentations

I use the word ‘typical’ with a pinch of salt as nothing in medicine is typical, but for the sake of the exam and a ‘typical patient’ here we go:

Migraine - one sided, throbbing, photophobia, lasts for a day, have to be in a dark room, +/- aura

Tension headache- ‘tight band around head’, worse in stressful situations, doesn’t stop ADLs

GCA- Temporal headache, scalp tenderness, jaw claudication, older patient

SOL- progressive headache, associated with N+V, worse in morning/leaning forward

Cluster - one sided, includes the eye, comes in clusters

Sinusitis - facial tenderness, associated with URTI symptoms, feel unwell

Meningitis (no typical) - fever, any age, may be associated with rash, acute onset, unwell, neck stiffness

Hoping as always you found this blog useful and it gave you something to inspire you to revise!

Keep working hard and think of the end goal.

Please contact me if you need any clinical skills help/revision. I provide communication and consultation skills training as well as covering the basics. Even if you want to spend an hour running through gastrointestinal conditions without any OSCE’s, we can do that. Email me below to enquire as to how I can best help you pass the exam!

Click here to email me

Happy revising x

4 reasons why I love to teach clinical skills

Hello fellow medics,

I hope you are all well in whatever part of the World you reside. Bringing happy and calm non pandemic vibes your way.

Today I wanted to just sit back and tell you why I do what I do….that is mentor and tutor CSA/OSCE skills. It is nice to reflect on the tutoring away from all the medical blogs!


The fun part of medical school

I don’t want to say OSCE skills came ‘naturally’, no one naturally knows how to communicate effectively or take bloods without practice. However, clinical skills and OSCE skills were the more ‘exciting’ part of medical school for me and what I enjoyed learning about. Fast forward to now, my job as a GP and a clinical educator has allowed me to ‘practice’ and refine these skills leading to me having the expertise to teach and mentor.

I am quite damn good at teaching

This one I can say comes naturally. I naturally like teaching, this may be medicine, this may be non medical things. I would say communication is one of my strengths and therefore I am able to articulate what I want to say and bring joy into learning. I have always partaken in teaching, but over the last 2-3 years, it has been my primary focus…and so far…I have a good pass rate for my tutees :) 100%.

Communication is key

It would not be much fun teaching something that was not relevant. Communication skills and OSCE skills in general are important for all doctors whatever you speciality or background. Having these skills are the difference between a successful consultation and a poor one, even if you have the greatest medical knowledge.

It doesn't feel like work

Working with medical students or medical graduates is such a fulfilling part of my day. Seeing someone in front of me excel and get more confident is absolutely amazing.

So that is why I do what I do!

Please get in contact if you would like any help with your clinical exams - this may be a reminder of the common conditions with less emphasis on OSCE practice OR pure OSCE practice. It is completely up to you how you want to do about it. We can do history skills, drug charts, examination skills - your choice.

Best of luck with the upcoming exams - whether that be medical school or the UKFPO.

L x