"Can you even examine me over video?" — remote back-pain triage

PLAB 2 & PRES 3 · remote consulting / musculoskeletal · medium · 10 minutes

Candidate brief

You are an FY2 doctor in a GP surgery conducting a video consultation. Mrs Emma Clarke, 38, booked online for back pain that started five days ago after she lifted a heavy box at home. She is at home, on her phone. She opens with: "I don't really see how this works — you can't even examine me over video, can you?" Please assess her remotely, reach a triage decision and agree a management plan.

What examiners look for

Remote consulting is not in-person consulting with the sound turned down — it is a different instrument with its own examination: the directed, narrated self-examination. "Walk to the door and back. Now up on your toes, holding the frame. Point with one finger to the worst spot." Each manoeuvre is chosen for what it can prove on camera, supervised for safety (furniture in reach), and interpreted aloud — because on video, thinking aloud is what examination looks like, and silence reads as guesswork. The red-flag history carries more weight remotely, not less. In the room, some of cauda equina's screen is examination; on video, all of it is questions — asked one at a time, in the patient's own vocabulary ("numbness around your bottom, like the bit that would touch a bicycle seat"), with the negatives documented individually. "No problems down there" is not a red-flag screen in any medium; on video it is malpractice with good lighting. Imaging is the consultation's second test. NG59 is clear that routine imaging for non-specific low back pain does not help and can harm — through labels, incidental bulges (common in people with no pain at all) and cascades. The friend's "missed disc" is answered by explaining what a scan would and wouldn't change today, not by ordering one to end an argument. Reassurance that survives is built from an examination the patient watched happen and a safety net she can recite — not from a picture of her spine. Analgesia is prescribed properly or not at all: NSAID first-line after an actually-performed contraindication screen, paracetamol's weakness for back pain acknowledged, opioids declined with reasons and alternatives. And the closing safety net is symptom-named and time-bound — cauda equina features with 999 attached, same-day triggers for the practice, a booked review with an in-person route — because in remote care the safety net is not the garnish; it is the discharge summary, the follow-up and the medico-legal record in one.

Guideline references

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