AMC Clinical Exam Orthopaedic

1. A 20 year old man working in super market come to you with shoulder pain after lifting 20kg carton_ Do a shoulder examination on him and your diagnosis and investigations Colless fracture of the radius. 68 y. o. lady had a fall on outstretched hand. Presented with pain in her wrist. AP and lateral radiograph of a Colles fracture. Asked to show - reduction technique. Anaesthesia/Bier block or general anaesthetic/. Dangerous signs/circulatory impairment/. After care. When are you going to see this patient next time, why? Rehabilitation.

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3. 60 years old lady postmenopausal, comes to see you because of L5 crush fracture. You investigate her for osteoporosis and her T-score is 3. TASK: Take further history and advise management. (Please ask relevant risk factor, Need to exclude other cause, when you order investigation, every test I ordered had been asked to give a reason, and examiner asked is there any blood problem need to be DDx, what the condition ? how to investigate ?) 4. Hip examination Patient has posterior dislocation of right hip 2 years ago. He came to you today for insurance examination. He has some pain when he is doing vigorous exercise. TASK: To examine his hip. Questions from examiner: Can he be insured? What are the probable complications of hip dislocation and how are you going to investigate? What are the possible complications of hip replacement? If you suspect of OA, what do you expect to see in the X-ray 5. A young man had right shoulder dislocation 6 months ago. He went through rehabilitation program and now feels fine. Examine him and advise him regarding his job as a labourer and sports ( he plays basketball and swimming) What nerve was most likely damaged? Any risk of recurrent dislocation? 6. A 54 year old woman presents with shoulder pain radiating to the neck and the thumb and index finger. Take the history and discuss management Examine the knee, and give a running commentary to the examiner while you examine. Dx, D/D. A young man R/knee injury due to a fall 6 months ago. The pain & swelling settled in a few days. He has R/ leg pain that disturbs his activities now. Twisted ankle Scenario: A 20y.o. female strained her right ankle while playing netball this am_ She came to see you for treatment TASK: examine her ankle, ddx and give treatment accordingly. TIP: Never forget to x-ray her.

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A 12-year-old girl presented to ED with history of fall on outstretched hand and swelling in the right elbow. You are provided with X-rays which showed supra condylar fracture without displacement. Task: Discuss the diagnosis and management with the mother. Examiner asked: What type of plaster would you use? Would you need general anesthesia for the patient? What would you advise the mother when they go home? Would you expect and what would you look for to exclude complication Mother asked when can the daughter go to school?

10. A 12-year-old child presented to ED with supra condylar fracture. Mother asked - would the reposition of fracture be under GA What are some complications? How long will you leave the plaster on After you remove the plaster, will the child be able to do normal activities. 11. (Surgery fractures of lower end of fibula) My Gya was the examiner There were pictures of the ankle joint with # of lower end of fibula which was minimally displaced. Task was to explain the findings to patient Mr Gya ask questions about weight bearing and follow up. 12. Knee examination- it was a medial meniscus injury and the chap was a rower (I had the examiner showing me what that was as r couldn't understand the Adelaide accent, I tout he said a ROARERIl!).I referred him to Sport Med. Examiner asked me what would the sport medicine specialist do?. 13. A 20 year old well fit man, had an eversion at the left ankle, and there is swelling of ankle joint, and couldnt walk after the injury. (long stem with description of the injury). You are an intern at ED. Task 1. Explain the xrays to the patient. 2. Advise on the management. The xrays (Anterior, Lateral) showed a fracture of lower end of the left fibula which was minimally displaced. I explained it to the patient as it is minimally displaced, Ill put him a below knee plaster upto toes at least for 6 weeks, before that Ill call orthopaedic for the opinion as the fracture at this site may become unstable, examiner told me that ankle is stable now, but Ive told him, it may be happen once the swelling reduced and the plaster loosened. Ill give him crutches for walking.and analgesics for pain. Then examiner asked can you see anything else? Actually I couldnt find anything at first, I said some problem in the talus bone, I took about 1 min,examiner told look at the anterior view, finally Ive seen the talus bone little bit displaced laterally. Then the examiner asked what would you do now? He need reduction, some special plastering, but I am not sure at the moment, Ill call the orthopaedic team. Patient asked Can I go for work Ive told him Once pain and swelling reduced, and fracture become stable, he can go. And I ll give you a leave certificate, and follow up x ray in 10 days, and follow him up until hes ok. And he needs rest now and early mobilisation later.

14. 12. 18 yr old boy, fell down and presented in ED/GP with pain and swelling in his left ankle. You sent him for X-ray's has arrived and the patient is waiting for you. TASK: Read the X-ray. Explain the condition to the patient Manage the case & answer patient's questions (#FIBULA WITH SUBTALAR DISLOCATION) 15. Foot pain. Young woman likes to going to the bush walk and having foot pain. The pain is worst in the morning. Task: Do PE of the foot or leg? 4 min and read X-ray, tell the diagnosis & Mx X-ray looks like osteoporosis. Pain is in only the sole Dx: Plantar fasciitis, could be Achilles tendonitis Mx: special shoe, refer to orthopaedics (what will they do? I don't know, that's fine) 16. Low Back Pain & the task was to examine the back, giving a commentory to the examiner explaining what you are doing and why. 17. A young man with right shoulder Anterior dislocation 3 months ago comes to Gp for checkup for a new job. Task: P/E. 18. Back pain radiating to leg (Sciatica) - examination and Dx

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A middle-aged patient fell of his motor bike and fractured his clavicle. Task: Management. Patient asked: Can I ride my motor bike? Can I drive my car then? How can I have a shower? Examiner Asked: What are you going to do for him? How to do the sling? For how long should the patient use the sling?

21. A lady sawer had a cut at the left hand, just above the 1st MCP joint. Bleeding had stopped already. GP setting. Tasks: Focused physical examination Management The patient couldnt extend her affected thumb, others were normal. Told the patient that the tendon responsible for extending the thumb was cut and she needed to be seen by a specialist to connect it and later to a physiotherapist to assist recovery of function. Examiner asked what else?, told him that I will give antiseptic dressing to the wound and also give antibiotics since it is a dirty wound, asked me again what else?, then the bell rang. Other questions asked: When will you refer to the specialist? (ASAP)

22. A 21 year old well ,fit young man has back pain.(ED) Task: Take further history Ask examiner the examination findings Tell the mx to the pt Sudden onset of backpain 2 weeks ago after lifting a heavy object. He thought it will become better, but it is worsening. Pain at the lower back area, 10/10, radiated behind the left leg towards the feet, constant pain, aggravated by sitting, coughing, activities, no fever ,n, v., no tummy pain, waterworks normal, no retention of urine, some tingling at the left foot. Bowels normal. Painkillers dont relieve the pain. Px no sig illness. O/EGA, VITALS NORMAL Back exam- Tenderness over left lower part of back, All movements restricted because of the pain. Special tests: SLRT- 30 degree at left, limited because of pain. Slumps test- Examiner not aware of it, and I tried to explain and he said he cant sit Neurological exam of lower limb: He asked what you want? Power- He asked which muscle. Ive told all flexion, extension of thigh, lower leg, feet,-Pain limits the movements Tone-normal Sensation-reduced at left side of left foot (S1) Reflex- What reflex you particularly want Ive told ankle reflex-negative Co-ordination normal Extensor planter response- normal. Abd exam-normal, urinalysis-normal To pt: With my clinical findings, Ive found that you have sciatica- that is there is your back bone, there are discs between them, openings where the nerves come out. Because of heavy lifting, disturbance in the discs and the compress the nerves , thats why you have severe pain. Usually we give conservative tx with rest, pain killers, and later exercise. But I am really concern that the nerve to left leg seems more affected. So I want to admit you, give pain killer, and call the specialists, and theyll do MRI SCAN,

23. A 25 yr old man fell on outstretched hand. You did the examination. There was tenderness over the right clavicle. Task: read X ray Tell what you are going to do and manage the condition with the materials provided. All materials included a sling and the ones for figure 8. Q s from the role player: How long do I have it on? 3 weeks Do I have a lump over the collar bone? Can I go to work? 24. Physical examination of a diabetic foot. Give commentery as you go along. After PE, you are asked about further management of the patient.

25. This is a traditional station. 55-60 y_o lady had a back injury I day ago_ As GP, you have ordered a spine x-ray which is show T9 fracture. Task: Tell pt and show the x-ray to her what is wrong on her spine. Outline you mgx plans Key: *Tell the pt and show her where is the fracture, (it is a real x-ray film): T9 body more than 30% wage fra+cture, need CT scan to confirm no nerve root involvement. * Pain relieve, bed rest, waiting for CT result, if something is wrong she will be referred to see orthopaedic surgeon.

*Life style change (hobbit, diet, active) to prevent osteoporosis, and explain what is that, how it is so easy to have this fracture. *Prescribe biphosphonate and let pt buy Vit D *Refer to physiotherapy, hydrotherapy for swimming, occupational therapy in future if possible * Review the pt after CT scan, if any change happened go to ED or call me at any time( From history pt has very good support at home from husband don't want to stay in hospital). * Information booklet of osteoporosis to pt. 20. A middle aged men presented with pain in the left shoulder, radiating to forearm and fingers. Task: take focused history Investigation and management Questions: -When did you notice the pain? Few days ago. -What type of pain? Burning -Do you notice any thing that makes it worse or better? Such as shaking your hands or put your hand over the edge of bed? No -How about the other hand? No, just in left hand. -Do you have chest pain? No, doctor, I cant write. -Have you had headache, blur vision? No. - How is your health in general? No diabetes, no hypertension. Id like to do physical examination. Examiner said: what do you want? Vital signs normal Heart, lung. Normal Upper limb neuro examination. What do you want to know? Power bicep, extension of the wrist decreases. Tone slight decrease Reflex bicep, tricep, brachioradial reflexes decrease. Sensation deltoid. Bicep, tricep, thumb and index decrease. He asked me what else do you want? - Maybe vibration or proprioception, I want to check the other hand as well. Normal, what else? I said I want to check the neck. - What do you want? Flexion decrease Palpation C5, C6 tenderness Extension normal no bleeding, no deformity Rotation decrease I told examiner that Id like to admit patient to hospital to do further investigations and treatment. What do you think patient has? Cervical spondylosis Cervical dysfunction Nerve root compression What investigations? FBE, CERVICAL X-RAY What else? MRI Again I told him that Id like to admit patient to see specialist. I do not know why I finished early. He told me you finished your task, you can go out.

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18 yr old boy, fell down and presented in ED/GP with pain and swelling in his left ankle. You sent him for X-rays has arrived and the patient is waiting for you. TASK: Read the X-ray. Explain the condition to the patient Manage the case & answer patients questions (#FIBULA WITH SUBTALAR DISLOCATION) Xray of Clavicle Fracture. Manage Elderly lady has sustained a fall on an outstretched hand and has pain and swelling in the wrist. Xrays have been provided Task: Examine the Xray & provide dx. Explain the mx to the patient and talk to the examiner Examine the shoulder and nerve injury. The 18 years old student playing in basketball competition. He had shoulder dislocation on the right and nerve injury. He already had an operation fixing it up 6 months ago. He came to your surgery asking you when he can go back playing basketball again. Examine the patient Advise the patient about returning to the competition The examiner was really old and very nice. I started examine the shoulder. Examiner asked: What nerve could be injured? Axillary nerve. Go on examine the patient. I examined for sensation on deltoid muscle and power (abduction) What else? The bell rang I was thinking about radial nerve as well, but not sure. So please check the books.

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Young lady playing basketball injured her ankle. Lateral ankle is tender with crepitus. TASK = Describing the X-ray film to examiner, discuss management and explain to patient. (fibula fracture) Lower back pain. Examination station. Had to conduct examination while giving commentary to examiner and ask examiner about physical signs. 35 year old woman, does bush walking regularly. C/o bilateral heel pain. No Hx of trauma. Task: exam both feet, read X-ray, give diagnosis and management advice. Knee pain. Examination station. 6/12 Hx of knee pain with lifting heavy weight. At the time of injury joint was swollen. Perform examination and provide commentary to examiner. Ask examiner about physical signs.

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A 6 week old baby boy is brought to the GP by his worried mother. You saw the baby 2 weeks ago and he was fine. You now find he has red finger marks on his back. Further examination and x-ray reveals a spiral # of his R) femur. 1st child. Mother states father is very busy. Your task is to take a relevant history and outline how you will manage this case.

10. Hip examination Patient has posterior dislocation of right hip 2 years ago. He came to you today for insurance examination. He has some pain when he is doing vigorous exercise. TASK: To examine his hip. Questions from examiner: Can he be insured? What are the probable complications of hip dislocation and how are you going to investigate? What are the possible complications of hip replacement? If you suspect of OA, what do you expect to see in the X-ray

11. Examination station. Lady with left shoulder pain. The pain is going down to left hand and includes left thumb and index finger. No Hx of injury. OE cervical spine tender. Xray results (from examiner) show narrowing most likely Dx cervical spondylosis but rule out cardiac causes 12. 26 year old man presented with sudden onset of back pain, pain and weakness in the R leg. Do not take any history, just do physical examination and advise management. 13. 66 yo man has come to you complaining of back pain and R upper thigh & back. He's been bricklayer labourer . He has had before some back pain. Task: Take further Hx & ask for physical examination findings Make diagnosis and discuss management 14. A 54 year old man comes to see the GP with a 2 week history of shoulder pain. 15. Your task is to take a further history, ask examiner for investigation results and discuss diagnosis and management with patient. 16. A young man with cut on the dorsal aspect of his left thumb. Hand examination. Manage. It was a tendon injury. 17. 29 y o male presents to you a GP with a 6 week Hx of tenderness in his L wrist. He is a mechanic. Hx Examine the hands! Dx and Mx (The pain was at rest and when using the hand. He had tried to rest it but relies on his job for income. The pain was mainly in his L thumb radiating from the wrist to the distal aspect of his thumb. Ex NAD) AMC: De Quervains tenosynovitis 18. Carpal tunnel syndrome. Diagnose and manage.