Clinical

Case Recall

Candidate Name Rita Joana Paiva da Cruz

Date of clinical 13.10.2017 Clinical Area Musc
exam (Neuro, Cardio-resp, Musc)

Hospital Name St. Vincents City & State Melbourne


Hospital Details & other information from Orientation:
(Access/transport to the hospital setting, details like acute Vs rehabilitation, inpatient Vs outpatient,
common type of patients seen there, location of the exam (ward Vs gym), equipment's available,
clinical records, do's and don'ts from specific local hospital policies etc)

I arrived by train, Parliament station. Follow the sign to Nicholson street and its about
200m ahead. It’s an old brick building, visible from the exit of the train station.

We were three candidates, all there for Musc exam. Statistically, you’re much more likely
to get inpatients than outpatients at St. Vincents, so all three of us were taken aback when
the very nice administrator lead us to the gym are and said “we are not going to the ward
today”. All pretended not to be disturbed by the news, but hearts were racing!

Anyway, administrator is really nice. Showed us the small individual cubicles where we
were going to have the appointment, took us to the gym (lots of exercise machines and
materials) and to the corridor, where meters are marked in the wall, making it really
simple to do walking tests. The place was nearly emply the whole morning, so I’m not sure
if they don’t do appointments when they have APC exams there. I believe she did not show
us a sample of the files but mentioned we would have one sheet of paper with organized
information we needed to know.


Information from history, charts & test reports:
(What did you have access to learn about the patient for e.g.files/digital investigation records,
observation chart, medications chart etc& What did you gather from that fore.g. Medical Hx,
Surgical Hx, Allied health assessment/ progress notes, premorbid mobility, social history, current
status of the patient etc - Please explain)

Administrator sat besides me, while I was reading the notes. She was very useful, helping
to translate handwritten notes I could not understand. She did say in the beginning
though, that she would not translate commonly used abbreviations. There was indeed a
sheet of paper with all necessary information, but it’s interesting how time passes quickly
and its hard to maximize the focus. This patient also had a bit of history, so beyond that
simple page where most of what I needed to know was, there was more complementary
details on other notes, from previous appointments that she also gave me.

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Information gathered:

HPC: Patient was admitted due to osteoarthritis. First documentation from the hospital
dated from February 2016, more than a year before the operation. He was then already
walking with 2FAC, L) knee flexion was 100º and extension -10º at that time. Because he is
not getting any more flexion range, there is a mention in the notes that he might be
submitted to manipulation under anaesthesia.

PMH: Increased BM, Chronic pain, double DVT

Physical Therapy: At the moment, walking with 2FAC, ROM 70º flexion, -5º extension.
There is record of a near miss fall last week.
Record of last session: 5 minutes stationary bike, mini lounges on step x20, mini squats
x10, knee forced flexion from seated position. Last three exercises taught as HEP. Ice after
exercise. There was also record of a 10MWT, recorded 3 days before. Results were 19.8s,
18 steps.

Social: At the time of first entry, 2016, patient was waiting for crisis accomodation. (I did
not understand what this meant and had to ask administrator, it basically meant patient
was homeless at the time, and crisis accomodation is accomodation offered to homeless
people, or so I understood). SSH at the moment, no stairs.

Administrator showed me x-rays, where you could see (and read) that there was no issue
with the prosthesis.
After the ten minutes had passed, she showed me two more documents (the first
documents, from 2016, explaining that because it was a difficult case, I could have one
more minute to read). Slight panic…. had I missed something? Why was it complicated in
terms of notes? Was there a stroke, cardiac arrest, what, what arrrrrghghhh… calm down!
I decided if there was something I missed I would have to find out in the interview (there
was not)
I grab a goniometre, a towel, a stop watch and tape measurer, as I thought I would need
them all for my initial plan.

Hypothesis presented to examiners:
(What did you understand about the patient and their problems and whatare your plans for
assessment and treatment options with this patient that you were expecting?)


55 year old male, with cemented L) TKR, 7 weeks post surgery. Walking with 2 FAC, which
he was already doing before the surgery. He’s a heavy man and at the moment his range of
motion is -5º extension and 70º flexion. He lives in crisis accomodation, SSH, no stairs.
There is a record of a near miss the previous week. My plan for today is check the falls
history and explore what might be behind, work on his range of motion and hopefully
have him walking a bit better, measuring it with the 10MWT, as there is a record of the
test done three days ago.


Preparation for an assessment/treatment:
(Preparing environment/collection of Ax tools, speaking to nursing/medical team, use of
gloves/masks etc)

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Collected a towel, a time watch, my gonio (there were several there, all sizes and shapes).
Hand hygiene.



Summary of findings from subjective assessment:
(Please summarise your thoughts and questions to thepatient)

Patient came walking with FAC and introduced himself to the examiners and to me. Very,
very, very nice man. He sat down on the plinth and I asked for consent.

Pain
Asked first about how he was feeling and pain levels. Pain was 3/10, when walking uphill
it’s when it gets works, about 5/10. Not irritable. Mentions he has taken pain medication
before coming to the hospital. Any other areas of complaint? He mentions his right knee.
Says his pain is 5/10 in that knee (so more pain than on the operated one). Says his R) leg
is bowed (varus presentation ). He basically also has ostheoarthiris on the other knee
and is waiting for the operation. Operation will not go ahead, though, if the L knee does
not improve.

Past medical history
I confirm the past medical history. DVT due to living and sleeping in a car for 7 years.
Many years ago had also undergone shoulder reconstruction but no problems there.
He mentions being obese (which he was not, really) and I take the opportunity to
mention the importance of diet, and how loss of weight is one of the best things he can do
for his knees. Ask him if he is taking care about what he eats. He says trying to eat more
fruit and vegetables and says a couple of things I don’t understand. He is funny and
extremely nice, but I can’t always understand his very strong accent, so I’m just hoping
I’m not missing on important information

Social history
Confirmed accomodation. Asked if he had any family. None. Any help with house chores?
He says he is independent and he managed everything - his house might not be as tidy as
it could be but he likes being independent. He mentions something about help, I don’t
fully understand but I get a general sense that there is no need to refer him to social
services because it’s all happening already.

Falls
I asked about the fall and how it had happened. He says he had slipped on the uneven
pavement, just outside St. Vincents. Confirmed there was no vision or hearing problems
and there was no other instances.


Short term and long term goals:
(Set in collaboration with patient)

Asked what he felt was his main problem at the moment, the main limitation. Said trust
and stability in his knee was lacking. We decided to try to work towards that today. As a
long term goal he would like to be independent and manage without crutches.

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Observation/Palpation:
(Posture, attachments, general appearance of the patient, resting in chair/bed/w/c,mobility,
neglect/inattention, tenderness, warmth etc)

When I started the interview the patient was sitting down on the plinth. As soon as he
arrived he took out the ZKS and the compression socks. I noticed early on that the
position was not great for his lower leg, so decided to get a stool. Could not find the
administrator and no stool so quickly came back to the cubicle and decided to help him
into long sitting in the plinth. The examiners had stopped the clock while I went to search
for the stool.
In this position, I quickly checked his upper limb ROM and strength, all good, pretty
strong, verbalized. Checked right leg, quick functional assessment also for gross ROM and
strength. Good and strong, verbalized. I was going to take a closer look at the knee, but
decided against it, as it was probably going to go for surgery.

Cleared DVT on both legs.

Observed and inspected the left knee. Not very tender on palpation. Checked the swelling
and measured it with a tape, comparing with the other side. I measured above the patella
and through the middle of patella. No difference above the patella but 5cm difference in
the midline of patella. Verbalized findings and explained importance of elevation, ankle
pumps and ice (that I knew he should be doing) to manage the swelling. Took a closer
look at the scar and found several adhesion spots. Did a very quick mobilization of the
patella and explained how he could do both patella mobilization and scar massage. It was
all a bit too quick and not very neat, but I did not want to spend to much time on this
techniques, so though that teaching him how to do the massage himself was actually
helpful for him.

Measured ROM. 60º Flexion, -5 extension. Grossly assessed strength through SLR, and
verbalised the problems I was finding: Pain, swelling, scar tissue adhesions, lack of range
of motion and lack of strength. From here on, assessment gets a bit mingled with
treatment.

Findings from impairment assessment and any special tests:
(Auscultation, SpO2, posture, cough strength, ROM, strength, muscle length, tone, sensory
assessment, visual field, neglect, pushers syndrome, reflexes etc )



Findings from functional assessment:
(Bed mobility, transfers out of bed/ chair, sit to stand, walking) with assistance required, aid used,
distance mobilised, rest given)



Summary of treatment provided:
(Impairment, functional re-education)

I said the problems of ROM and strength should be both addressed by the exercises he is

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performing, and asked him to show me what he was doing at home. He showed me SQ and
then SLR - I corrected by helping him first activate last degrees of quads (SO) before
lifting the leg, and trying to maintain that activation. Showed me heel raises and here I
picked up a towel and tried to have him self increase flexion. He was doing all sorts of
compensations with the trunk but was trying his best, and going well into his pain. I
reassured him that even though not pleasant, he should be going into his pain. We did
this all this exercises 10 times. I reminded him that he should do them in sets of 3 and 3
times a day.

I quickly reassessed his knee ROM, in case I would not have time at the end. Flexion had
improved 10º and was now 70º. I verbalized the improvement in just 10 exercises.

Then asked him what other exercises. He showed me appling forward pression when
sitting and he was doing it all wrong, legs to much forward, not really forcing flexion, so
again I corrected him. Showed me pushing the L leg with the R leg into flexion. I said good
but he should also try to take the leg by itself, to activate hamstrings.

He then showed me squats. I think we performed the exercise 10 times and I also gave
him some corrections along the way.

I then wanted to check balance, but time was running out, so very quicky I gave him my
hands for support and asked him to do a SLS alternating legs. He was pretty shaky on
both legs, but mainly on the left. I said I would like to work a bit on proprioception, as I
understand that there is lack of strength and lack of ROM, but I believe there is also a loss
of proprioception that he is verbalizing as a “loss of trust” in the knee. I got a blue square
foam from the gym and asked him to step on it. Again, holding my hands, we did SLS and
squats on the foam. We did maybe 10 repetitions, not sure. 40 minutes were up and I still
had not walked the patient. At the end I asked him to step out of the foam and do a slow
SLS, trying to feel where his knee and feet where, and trying to control them. He had
much better response, in terms of time and quality of stance, unfortunately I had not
measure, so could not use it as outcome measure.

As we were running out of time, I ask the patient if he would mind going for a walk
barefoot. Of course he wouldn’t, he was just the sweetest man, trying his best to follow all
that I was saying and asking him to do. So we started to walk to the corridor, where the
marks for the 10MWT were. I noticed he was not walking heel to toe, so gave him that
feedback and also that his steps were very big, which left him more at risk of falling.
Asked him to pay better attention to how he was placing the feet and try to diminish the
length of the steps. Gave him instructions and he did a better performance: 98s and 16
steps (now that I came to think of it, it’s actually not that great that he was doing less
steps!)


Reassessment and outcomes:
(Qualitative & Quantitative)

We went back to the cubicle and I still had time to reassess again the ROM: It was still at
70º. I verbalised that it was still better than when he arrived, and that the walking test
had improvements. Encouraged him to keep on doing the exercises, wished him all the
best with the rehabilitation and thank him for being my patient.

Room exercise program:

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(Repetitions - sets)

Same program he had with the described corrections

Viva questions and your answers:

- Can you prioritize the problems of the patient?
Pain, loss of ROM, loss of strength and proprioception, swelling, affecting his walking
capacity and his independence

- Was he performing real knee flexion?
I did not understand at first what the examiner meant, and though she was talking about
the gonio measuremnt. I did realize that he was doing a lot of trunk compensations, but
that was not affecting the reading. I mentioned the compensations anyway, present also
when he was doing squats. I think this was what she meant.

- Which landmarks did you use to measure the knee swelling?
Above the patella and middle patella

- What measurement did you use for balance? (the question was not verbalized like this
but I can’t remember the proper terms)
I said I decided to just do a quick functional test of balance, by asking him to perform a
SLS on each leg, as I was running out of time and just quickly wanted to know if it was an
issue or not that I should address

- Was his range of flexion what you would expect for a 7 week post op?
No. You would expect at least 100º of flexion. There is some problem going on.

- What would you do next time?
I would probably use the gym. I didn’t want to do it in an exam situation, but there were
lots of props in the gym, like steps, exercise machines and other proprioception aids - I
pointed and mentioned them. I also said that I would still look at the adhesions in the
scar and check that he was doing the exercises correctly.

Discussion / Reflection:
1. What were your thoughts on what you did well?

I kept calm all the way.
All the interventions were simple, but they responded to one issue I found in the
assessment.
Everything had a clear clinical thinking behind. Even if there was no brilliance in the
results, clinical thinking was there all the way.
I kept simple and uncomplicated

2. What could you have done better?

I could have used the gym and make it a much more interesting and rewarding session
for the patient. But not necessarily a better exam tough…

3. What are some of the barriers to your performance during the exam?

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Instead of barriers, I had a help: a beautiful patient who was so keen to help.

4. What do you think helped you in performing this exam well? (Any courses, observational or
training opportunities attended, books / manuals read for your preparation)

- Mock exams. I only did one, but totally set me on the route to improve my mistakes.
- Practice. Again, I could not practice much, but Urvi, those two days at your house were
precious!!!
- Recalls. Soooo helpful too.
- Orthopaedic guidelines, APA online courses

5. Tips for other members

Keep it simple. Guide your treatment according to what you find in the assessment. The
session does not need to be brilliant and you do not need to be an expert – if you are
great, but you really don’t need to be. What the session needs is to be safe, it needs to
show clinical thinking: find a problem; treat it accordingly even if in the simples way. And
establish a connection with the patient!

Was the outcome of your exam positive? When did you receive your result (Date)?

Yes Yes in all Yet to Receive
criteria
19/10/2017
No



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