WHAT IS THE CLINICAL
FEATURES PROBLEM?
A feature of clinical
problem is the issue related to the context of clinical medicine and it is more
a tool. The summary of clinical feature problem is one or some trigger clinical
signs for discussion between the Candidate and the Examiners. These triggers
are always relevant, interesting and provocative at the discussion in the
orthopaedic and traumatologic exam. The clinical problem could be documented in
writing, photos of clinical sign, audio or video tape.
Adequate discussion of
the trigger clinical features is important and there are a number of strategies
to ensure the objectives and transparent, valid and reliable marks achieved.
Therefore, the discussion of the key feature of clinical problem is a
fundamental aspect for the Candidate passing in orthopaedics and traumatologic
examination objectively. The discussion may be extended the basic medical and
clinical sciences questions by the Examiners (illustration 4).
Illustration
4: Extended of Question’s discussion
a.
SEPTIC ARTHRITIS OF THE KNEE JOINT
SCENARIO:
A–17-year
male came to consultation with complaint of pain with swollen of the right
knee.
Learning
Objectives Evaluation in Examination
The Examiners
should be able to evaluate:
a.
The Candidate
ability to complete the history taking, physical examination and investigation
related the possibility or accurate diagnosis of the illness
b.
The Candidate
ability to predict acute and long-term problem of the illness
c.
The Candidate
ability to plan the management and outcome
d.
The Candidate
ability to predict the complications.
e.
The Candidate
ability to have a good attitude and professionalism
How the candidate solves the patient complaint
According
to the scenario and patient complaint, the Candidate should be able to summarize
that epidemiology: patient is male and young, clinical feature: history of the
illness and physical examination and investigations are incomplete (table ?).
The Candidate is able to ask some questions for collecting history taking,
physical examination and investigations for achieving accurate diagnosis.
The Candidate should
be able to predict probabilities of the patient based on pain and swollen body
part complaining such as: (1) trauma for instances fracture or dislocation of
the right knee or (2) non - trauma such as: infection, inflammations, degenerative
joint or malignancy of the right knee.
The
Examiners are able to evaluate the Candidate ability to complete the key data
for analyzing. The Candidate is able to
explain the discussion questions of the Examiner. It depends on
his/her experiences of the Examiner for getting the objective, valid and
reliable mark.
Part
A: The objectives examination evaluation of the history taking, physical
examination and investigation data collection for some possibilities or accurate
diagnosis determination
Learning Objectives Evaluation in Examination
a. The completeness
of information or data for accurate diagnosis or other possibility
The first
the Examiner question: What’s the possibilities according to scenario?
According to the scenario and patient complaint, the Candidate should be
able to consider a conclusion and much information or data must be collected completely
(table 31).
Table 31:
List information of the scenario
Medical sciences
|
Information
|
Epidemiology
|
Male and young patient
|
Clinical features:
|
·
History taking: Pain (incomplete information)
·
Physical examination: Swollen (incomplete
information)
·
Investigation: No information
·
Diagnosis: should be discussed
·
Acute and long-term problem should be discussed
|
Anatomy and pathophysiology
|
The Examiners Should be able to discuss
|
Management, promotion and prevention
|
The Examiners Should be able to discuss
|
complications
|
The Examiners Should be able to discuss
|
The Examiners are able
to evaluate the Candidate ability of some questions for collection history
taking, physical examination and investigations data or information based on abnormality
probabilities of the patient. The Examiners are able to discuss the incomplete
or no information and others on table 21 above. The Candidate should be able to
predict the illness probabilities of the patient based on pain and swollen
complaining such as: (1) trauma for instances fracture or dislocation of the
right knee or (2) non - trauma such as: infection, inflammation, degenerative
joint or malignancy of the right knee.
The Examiners are able to evaluate the Candidate ability to complete the
key data for analyzing. The Candidate is
able to explain the discussion questions of the Examiner. It depends on
his/her experienced of the Examiner for getting the objective, valid and
reliable mark.
The
Candidate is able to ask the other symptoms in history taking and clinical
signs of the physical examination and investigations for achieving septic
arthritis of the knee joint diagnosis. The Examiners evaluate the ability of
the Candidate to collect the entire data/information. The Candidate focuses on
clinical feature problem while considering the probable abnormalities or illness,
subsequently to complete the data of every differential diagnosis (hypothesis).
The Examiners will discuss every Candidate’s question about his/her reasoning.
How the Examiners evaluate the Candidate ability to sort a cluster of clinical
features of the patient. The Examiners evaluate how the Candidate integrate,
interpret and analyze all the data for making probabilities or accurate
diagnosis (clinical reasoning). The Candidate is able to explain the discussion questions
of the Examiner. It depends on his/her experiences of the Examiner for getting
the objective, valid and reliable marks.
The Candidate ability to present that patient has a trauma one week ago
and there was wound on the dorsal of the right forefoot. The patient was able
to walk without limping. Because of that, the Candidate is able to predict
infection or sepsis is first choice (wound is the risk factor) and then
inflammation, degeneration, and malignancy of the right knee based on patient’s
complaint. The Candidate can exclude degeneration because of age and without
malignancy history. Based on collection of data, the Candidate is able to
determine: A- 17- year male, inability bearing weight, history of excoriation
on the anterior of the patella cause of trauma one week ago, febrile and
tachycardic. Physical examine data: swollen, erythematous, elevated temperature
at right knee, positive fluctuation tests and limited movement of knee joint.
Laboratory values WBC, ESR and C-RP (45 mg/L) are a bit elevated. Radiographs
examination showed widening of the articular space. The patient denies
malignancy and inflammatory history and he is a young patient. Synovial fluid
aspiration supports infection process (staphylococcus aureus microorganism is positive).
Analysis synovial fluid shows a WBC is more 50.000/mm 3 but WBC is
less elevated in gonococcus joint infection. Septic arthritis cannot be
excluded if negative culture in chronic condition that cause of by organism of
low virulence. Acute rheumatic fever or juvenile rheumatoid arthritis and CPPD
should be excluded by the clinical signs and laboratory investigation data. Conclusion
is septic arthritis of the knee joint. The Candidate ability to explain the
septic arthritis of the knee joints that cause of microorganism inoculation
into the joint directly by penetration or hematogenous.
Part
B: The objectives examination evaluation of
the patient’s problem, management and complications
Learning Objectives Evaluation in Examination
a.
The
Candidate ability to decide acute and long-term problem of the illness
The
Examiner will discuss the acute and long-term problem based on the Candidate
hypothesis and severity of the septic arthritis of the knee joint. The
Candidate will contribute his/her view perception on a problem and the
Examiners evaluate the Candidate ability to explain the solution of patient’s
suffering or accurate diagnosis and how the Candidate to prevent by promoting the
septic arthritis of the knee joint for individual and community. The
Candidate is able to explain the discussion questions
of the Examiner. It depends on his/her experiences of the Examiner for getting
the objective, valid and reliable marks.
The Candidate has an ability to explain that septic arthritis is the
most common caused by direct or indirect inoculation of bacterial and grow well
in the knee joint. The condition is an orthopaedic emergency management. Septic
arthritis of the knee joint can damage the articular hyaline cartilage due to
the release of proteolytic enzymes from the bacteria as well as host synovial
cells, chondrocytes and inflammatory cells. Proteolytic enzymes include
collagenase, elastase, hyaluronidase, lipase and lipoproteinase. Bacterial
virulence factors also contribute to cartilage destruction for example is
coagulase produced by staphylococcus aureus and it can impair intracapsular
vascular supply due to small vessel thrombosis. The increasing of
intraarticular pressure of the knee joint cause of pus accumulation contributes
reducing of patient’s immune response. In acute problem of septic arthritis is
bacteremia or a systemic inflammatory syndrome (SIRS) with the signs are
tachycardia, tachypnea, hypotension and end organ damage particularly
immunocompromised patient. Some publications reported the mortality rate about
10%. Long-term problem are degeneration and fusion of the joint. In infants and
children may contribute to joint destruction or physeal damage and then growth
problem. Loss knee joint function
usually occurs in older patients and chronic infection may never be eradicated.
Others problem of septic arthritis management are antibiotic allergy and
aspiration synovial fluid aspiration. Technique aspiration procedure must be
aseptic method strictly.
b.
The
Candidate ability to plan the management and outcome
Acute septic arthritis of the knee
joint is emergency antibiotic therapy and decompression surgical drainage
should be considered (Red Flags).
The
Candidate is able to tell the outcome or prognosis after intervention or
without treatment and complications of the illness in the discussion with the
Examiners. The Candidate is able to explain the discussion questions
of the Examiner. It depends on his/her experiences of the Examiners for getting
the objective, valid and reliable marks.
The Candidate should be able to start broad spectrum antibiotic
intravenous injection as soon as possible after obtaining joint fluid
aspiration for microorganism culture and then the antibiotic will be changed
based on the result of the sensitivities test. Furthermore, surgical
decompression, irrigation and drainage by arthroscopic should be considered.
Open arthrotomy is an indicated because of rapid, irreversible cartilage damage
or no improvement to antibiotic treatment in 24 to 48 hours. In chronic
situation, fusion of the joint or even amputation may be considered. Splinting
immobilization should be applied during infection subsided and then start
rehabilitation of the knee joint. The result of this management are good
because of function will be normal.
c.
The
Candidate ability to predict the complications.
The complications have been discussed above (a).
Part
C: The objectives examination evaluation of a
good Candidate’s attitude and professionalism.
Learning Objectives Evaluation in Examination
1. The
Candidate ability to show a good attitude in the illness health care services
in septic arthritis of the knee joint discussion. What is Candidate plan the beneficence management
orientation and avoid malaficence in the health care intervention on the
discussion?
2. The Candidate ability of good
professionalism in septic arthritis of the knee joint health care services
·
The Examiners should evaluate the professionalism of the
Candidate. He/she should enhance the quality of medical care delivered based on
biopsychosociol-cultural knowledge for patient in septic
arthritis of the knee joint discussion.
·
The Examiners should evaluate the Candidate decision making
of the priority management among some options based on the evidence of medicine
(EBM) in the discussion. What is the candidate management decision in health
care and the reasoning of explanation mechanism, advantages and disadvantages
clearly and knowledgeable to the patient?
·
The Candidate is able to explain the discussion questions
of the Examiner. It depends on his/her experiences of the Examiner for getting
the objective, valid and reliable marks.
Table 32. List of septic arthritis of
the knee joint evaluation
PART A:
The objectives examination evaluation of the
history taking and physical examination data collection for diagnosis or
other possibilities determination
|
30
(complete
& correct)
|
20
Incomplete
presentation or correct response of
stimulation question
|
0
(incorrect
or no response)
|
Marks
|
The
Candidate ability to complete the history taking, physical examination and
investigation related to the septic arthritis of the knee joint in discussion
|
||||
PART B:
The
objectives examination evaluation of the patient’s problem, management and
complications
|
20
(complete
& correct)
|
15
(incomplete presentation or correct
response of stimulation question
|
0
(incorrect
or no response)
|
Marks
|
1.
The Candidate ability to predict
acute and long-term problem of the septic arthritis of the knee joint in
discussion
|
||||
2.
The Candidate ability to plan the
management and outcome of the septic arthritis of the knee joint in
discussion
|
||||
3.
The Candidate ability to predict the
complication of the septic arthritis of the knee joint in discussion.
|
||||
PART C:
The
objectives examination evaluation of a good Candidate’s attitude and
professionalism.
|
10
(complete
& correct)
|
6
(incomplete presentation or correct
response of stimulation question
|
0
(incorrect
or no response)
|
Marks
|
The Candidate ability to show good attitude and professionalism
in septic
arthritis of the knee joint discussion
|
||||
Total marks (Part A
+ B + C)
|
||||
MARKS:
Part A: The
Candidate ability to complete the history taking, physical examination and
investigation related to the possibility of the illness
:
- Marks 30:
Candidate presents the history taking, physical examination and investigation
and analyze key data of the septic
arthritis of the knee joint completely and correctly
- Marks 20: Incomplete
data presentation or the Candidate is able to respond the examiner’s
stimulation question about a mistake or omission of the interesting
history taking or physical examination and investigation needed or a
mistake analyzing data of the septic arthritis of the
knee joint correctly.
- Marks 0: Candidate’s response is not correct or he/she does not respond
to the examiner’s stimulation question of history taking, physical
examination, investigation and analyzing of the key data
of the septic arthritis of the knee joint
Part B: The objectives examination
evaluation of the patient’s problem, management and complications
:
- Marks 20:
Candidate presents the acute and long-term problem or management planning,
or complications prediction of the septic
arthritis of the knee joint completely and correctly.
- Marks 15: Incomplete
data presentation or the Candidate is able to respond the examiner’s
stimulation question about a mistake or omission of the interesting of
the acute and long-term
problem determination or management planning, or complications
prediction of the septic arthritis of the
knee joint correctly.
- Marks 0: Candidate’s response is not correct or he/she does not respond
to the examiner’s stimulation question of the acute and long-term problem determination, management planning, and
complications prediction of the septic
arthritis of the knee joint
- Maximal marks
of part B is 60
Part C: The
objectives examination evaluation of a good Candidate’s attitude and
professionalism:
- Marks 10: Candidate ability to show a good
attitude and basic medical
and clinical knowledge to decide management based on evidence (professionalism) in health care
services of the septic arthritis of the
knee joint
- Marks 6:
Impolite attitude in discussion between Candidate and patient/Examiners
but the Candidate is a good basic medical and clinical knowledge and
management decision based on evidence in health care services
of the septic arthritis of the knee joint.
- Marks 0: Impolite attitude and Candidate is
also a bad basic medical
and clinical knowledge without evidence management decision in health care services of the
septic arthritis of the knee joint
Table 33. Other evaluation list of septic arthritis
of the knee joint
CONTENTS OF
EVALUATION
|
Marks
|
|||
Part A:
The objectives
examination evaluation of the history taking, physical examination and
investigation data collection for some possibilities or accurate diagnosis
determination
|
30
(complete
& correct)
|
20
complete presentation or correct response of stimulation question
|
0
(incorrect
or no response)
|
Marks
|
Ability to collect the key data of the history
taking, physical examination and investigation data collection for septic
arthritis of the knee joint
diagnosis determination in discussion
|
||||
Part B:
The objectives
examination evaluation of the patient’s problem, management and complications
|
60
(complete
& correct)
|
45
(incomplete presentation or correct
response of stimulation question
|
0
(incorrect
or no response)
|
Marks
|
Ability to determine acute and long-term problem,
select the best option of the management
and to decide the complication of the septic
arthritis of the knee joint in discussion
|
||||
Part C:
The
objectives examination evaluation of a good Candidate’s attitude and
professionalism.
|
10
(complete
& correct)
|
6
(incomplete presentation or correct
response of stimulation question
|
0
(incorrect
or no response)
|
Marks
|
Ability to show a good attitude and
professionalism in the septic arthritis of the knee
joint discussion
|
||||
Total Marks (Part A + B + C)
|
||||
MARKS of Part A:
- Marks 30:
Candidate presents the history taking, physical examination and investigation
and analyze key data of the septic
arthritis of the knee joint completely and correctly
- Marks 20: Incomplete
data presentation or the Candidate is able to respond the examiner’s
stimulation question about a mistake or omission of the interesting
history taking or physical examination and investigation needed or a
mistake analyzing data of the septic arthritis of the
knee joint correctly.
- Marks 0: Candidate’s response is not correct or he/she does not respond
to the examiner’s stimulation question of history taking, physical
examination, investigation and analyzing of the key data of
the septic arthritis of the knee joint
MARKS of Part B:
:
- Marks 60:
Candidate presents the acute and long-term problem, management planning,
and complications prediction of the septic arthritis of the knee joint completely
and correctly.
- Marks 45: Incomplete
data presentation or the Candidate is able to respond the examiner’s
stimulation question about a mistake or omission of the interesting of
the acute and long-term
problem determination, management planning, and complications prediction
of the septic arthritis of the knee joint correctly.
- Marks 0: Candidate’s response is not correct or he/she does not respond
to the examiner’s stimulation question of the acute and long-term problem determination, management planning, and
complications prediction of the
septic arthritis of the knee joint
MARKS of Part C:
·
Marks 10: Candidate ability to show a good attitude
and basic medical and clinical knowledge to decide
management based on evidence (professionalism)
in health care services of the septic arthritis of the
knee joint
- Marks 6:
Impolite attitude in discussion between Candidate and patient/Examiners
but the Candidate is a good basic medical and clinical knowledge and
management decision based on evidence in health care services of the
septic arthritis of the knee joint.
- Marks 0: Impolite attitude and Candidate is
also a bad basic medical
and clinical knowledge without evidence management decision in health care services of the
septic arthritis of the knee joint
Conclusion = Part A + Part B + Part C
·
Marks:
85-90 is superior
·
Marks:
79-84 is excellent
·
Marks:
69-78 is pass; and
·
Marks:
60-68 is fail
|
·
Marks:
85-90 is superior
·
Marks:
76-86 is excellent
·
Marks:
65-75 is pass; and
·
Marks:
≤ 65 is fail
|
KEPUSTAKAAN:
1. Adam JC
(1978). Outline of Fracture.
Churchill Livingstone. London
2. Armis
(2005). Musculoskeletal Competency:
Guidelines for Medical Students, PCPs (Primary Care Physician) and Residents in
Training. Unit Pelayanan Kampus. FK UGM. Jogjakarta.
3. Beaty JH
and Kasser JR, edits (2008). Rockwood and Wilkin Fractures in Adult. 7 th
edition, Lippincott Williams &
Wilkins. Philadelphia USA
4. Bernstein JB (2008). Musculoskeletal Medicine. AAOS, Rosemont
5. Canale ST
and Beaty JH.edits (2013). Campbell’s
Operative Orthopaedics. 12th edit. Elsevier. Philadelphia USA.
6. Greene WB.
Edit (2001). Essentially
Musculoskeskeletal Care. AAOS, Rosemont
7. Solomon L
and Nayagam S (2010). Apley’s System of Orthopaedics and Fractures. 9th
Edition, HODDER & ARNOLD, London, British.
8.
Toy EC, Rosenbaum AJ, Robert, TT and Dines JS (2013). Case Files: Orthopaedic Surgery. McGraw
Hill Education. New York.
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