Case format and tips for a short Orthopaedics case presentation

Orthopaedic cases are presented as short case in examination. The candidate is given a brief time of 10-20 minutes to evaluate each case. Hence, it is important that he/she must know art of quick evaluation and crisp presentation.

General format for presentation

Name                        Age                        Sex                       Occupation                         Address

Initial demographic data can be said as “Mr. AB, 28 year old male from Bangalore health worker by occupation is a right handed person presents with chief complaints…”

Handedness (especially in upper limb case)

Chief complaint (in chronological order)

1. AA
2. BB
3. CC

History of present illness (HOPI):

-Description of each chief complaint separately

-Important positive history

-Important negative history

Past History:

Personal history:

Treatment history:

Family history:

Menstrual history:

At the end of the complete history taking, the candidate must be able to arrive at some conclusion about broad category of the diagnosis. The disease could be Congenital: present from birth/late presentation Traumatic: H/O trauma Inflammatory: e.g., Many joints involved, malaise, multi-system affection Infective: H/O fever Neoplastic: H/O rapidly growing swelling, loss of weight, appetite, Metabolic: Osteoporosis, gout with relevant history Degenerative: Mostly age related Osteoarthritis, tendinitis Others. So, while taking history, student must take relevant positive and negative history from each category to rule out other category

 

A very common mistake during case presentation is mixing treatment history with HOPI. It should always be avoided. It takes away the focus from HOPI. Only case where one can mix present history with treatment history is a case of trauma whereas in all other cases, treatment history should be mentioned separately.

 

Examination

• General examination & Systemic examinnation
• Local examination

 

1. Gait (in case of lower limb)
2. Attitude
3. Inspection
4. Palpation
5. Movements
6. Measurement
7. Neurovascular examination
8. Special tests for individual pathology
9. Joint above and below

• Final diagnosis

Final diagnosis should have following components. Duration Anatomical Site Side Pathology Etiology Complication, if any

 

Example of a complete diagnosis: One year old, right side tibial shaft non-union due to road traffic accident with shortening.

Description: One year old (duration) Right side (side) tibial shaft (anatomical site) non-union (pathology) due to road traffic accident (etiology) with shortening (complication)

Diagnosis should be based upon points favoring the diagnosis from history and examination. Student must not give the diagnosis based upon negative points It is not ALWAYS essential to give a differential diagnosis. Eg. There will not be any differential diagnosis for tibial non-union. However, there can be differential diagnosis in patients with rheumatoid arthritis of knee.

 

Certain tips while performing examination:

1. General and systemic examination should ALWAYS be done. However,

A) If general examination is normal, it can be said as “general examination normal”. If there is a significant abnormality, it should be informed. e.g., “pallor present”.

B) If Systemic examination is normal, it can be said as “systemic examination normal”.

In case of a disorder which has a systemic effect or it is a part of systemic illness like Rheumatoid arthritis/ tuberculosis, it is important to do quick systemic examination.

During regular case presentation/exam viva, it is wrong to say that “I have not done the general or systemic examination”. It should always be done even in short cases. If both are normal, it can be summarized as “general and systemic examination normal” and candidate should focus upon the local examination as orthopaedic cases are given as short case.

 

2. In the category of movement, candidate should mention like this example. Knee movement: 0- 100⁰. 0-90⁰ is painless whereas rest 10⁰ is painful. Further is not possible. Both active and passive are same.

Avoid adjective like “knee movement is full/ very good”! Examination is an objective assessment and no adjective should be added during examination.

 

3. In the category of measurement, one can straight away tell the discrepancy/normalcy of limb length rather than narrating the individual measurements of limb and not calculating the final discrepancy.  Example; during examination, a student measures the individual length of bone. The objective of limb length measurement is to analyze the discrepancy in the limb length, if any and to assess the area of discrepancy (femur/tibia/both.. etc)

 

Usual, but wrong way of answer: “The right femur is 52 cm long and right tibia is 35 cm long. The left femur is 52 cm long and left tibia is 33 cm long”. After this statement, many students think that the job is over. After the individual measurements of bones, goal is to measure the “limb length discrepancy” which is 2 cm short tibia in this case.

So, simple way is calculate the discrepancy, if any and answer accordingly.

Simple and right way of answer:  “The right lower limb is two cm short as compared to the left, and the shortening is in tibia”.

If the limbs are equal in length, then saying that “There is no limb length discrepancy” is enough.

 

During the presentation of short case, examiner is not interested in the individual measurement of bone length.

 

4. In the category of neurovascular (NV) examination:

 

• If the NV examination is normal, it can be said as “neurovascular examination is normal”
• If the NV examination is abnormal, then individual finding should be told. E.g., if pulse is absent but neurological examination is normal, then it is appropriate to say that “neurological examination is normal. However, Dorsalis pedis artery is not felt on right side”

5. Joint above and below should be examined. So, in case of a knee pathology, if they are normal, it can be again summarized as Joint above (hip) and ankle (below) is normal.

However, if there is an abnormal finding, it should be informed.

While presenting the finding of the case, two things to be avoided unless asked for Methodology of examination Etiology of finding.   Classic example is limb length. How the student examines and what is the cause of short limb is not to be presented while presenting the finding that the tibia is short in measurement section. If examiner asks that, how did you measure the limb length; only then examinee should inform the methodology. Also, why the tibia is short should be kept reserved for discussion and not to be told during finding presentation. Example; tibia is short because of bone loss during accident.