MCP Flashcards
Question 1: Your outpatient is a 21 year old man who received a renal transplant three months ago and was administered Gentamicin for two weeks postoperatively.
Now he can walk independently but feels unsteady when walking in the dark and on uneven surfaces. When he moves quickly his vision is blurred.
Perform appropriate clearing assessment procedures.
Perform two (2) safe and appropriate assessment techniques that you strongly anticipate would be positive/abnormal in this patient.
Clearing assessments:
Cervical examination
VBI
Hold extension (30˚) and rotation(45˚) for 30 seconds each side
Check for:
5D’S = diplopia, dizziness, drop attacks, dysarthria, dysphagia,
3N’S = nausea, numbness and nystagmus
Cervical AROM/PROM
Any pain/ dizziness etc
Assessment techniques:
Head impulse test
Positioning: seated with therapist below eye-line e.g. kneeling infront
Method:
Position 20-30° cervical flexion to ensure horizontal canal sensitivity
Thumbs over cheek bones, don’t cover ears
Ask pt to keep eyes on your on nose
Quick & unexpected turn of head in L & R direction
Looking at the way the eyes are able to keep their head up or are delayed. Can the pt keep their eyes fixated on therapists nose
Outcome:
Positive: eyes are slower than head
Negative: eyes stay focused on nose constantly even when head moves
Dynamic visual acuity test
Positioning: seated 6m from chart, therapist behind patient
Method: assess if the head turns affects vision
Ask pt to read the letters on lines with head still and record baseline
Repeat with hands on head moving L to R short and sharp
Compare how far they got - 2 lines deviation is normal !!
Outcome:
Positive: >2 lines deviation
Negative: < or = to 2 lines deviation
Question 2: A local G.P. has referred you a 55-year-old woman with “possible Benign Paroxysmal Positional Vertigo (BPPV)”.
Perform appropriate subjective assessment to help confirm the diagnosis of BPPV.
Perform safe and appropriate physical examination procedures to help confirm the diagnosis of BPPV.
Subjective assessment :
HOPC
When did you first notice your symptoms (changing head positions)
How often are episodes
How long do they last? (<2mins)
Is your dizziness here all the time or does it come and go?
Falls during episodes?
Result of Trauma? Concussion? Head strike?
Affect ADLS like driving?
Have family members noticed any changes to your mobility?
PMHx
Stroke?
Head trauma?
Brain injury?
Motion sickness?
Associated symptoms
nausea, vomiting, double vision, fainting, hearing loss, ringing in ears, or headaches
Type of dizziness?
Spinning?
Is it in one position or different positions?
Aggravating & easing factors ?
Aggs of rolling over in bed (more likely horizontal)
Aggs or lying down in bed/looking up/getting out of bed (more likely posterior)
Objective:
- VBI:
5D’S = diplopia, dizziness, drop attacks, dysarthria, dysphagia,
3N’S = nausea, numbness and nystagmus
Hallpike: (posterior)
Roll: (horizontal)
Question 3: A local G.P. has referred you a 55-year-old woman with “possible Benign Paroxysmal Positional Vertigo (BPPV)”.
1. Perform safe and appropriate physical examination procedures to help confirm the diagnosis of BPPV.
2. Perform appropriate treatment based on the patient’s responses.
- VBI:
- Hallpike (posterior)
- Roll test (horizontal)
Treat:
4. Either Epley’s or BBQ Roll
Question 4: Your inpatient is a 65 year old man who had a (L) brainstem infarct 1 week ago. He complains of vertigo which is slowly improving but still feels very unsteady. You notice that he walks with a wide base of support, and he needs close supervision when on his feet.
Perform three (3) safe and appropriate assessment techniques that you strongly anticipate would be positive/abnormal in this patient.
TEST OF SKEW
Positioning: sitting up
Method:
Cover eyes one at a time and ask pt to keep looking straight ahead
Quickly move your hand to cover the patient’s other eye while they keep looking straight ahead.
Positive: Uncovered eye nystagmus or corrective movement
SMOOTH PURSUIT - H & X
Positioning: sitting up
Method:
Ask pt to follow the pen with eyes without moving head
‘H’ shape and ‘X’ shape for diagonal
Positive: nystagmus or unable to follow or movement is disjointed
VOR SUPRESSION
Positioning: sitting up
Method:
Instruct them to keep eyes focused on their thumbs infront of them
Get them to move L & R, keeping eyes on thumbs
Positive: nystagmus or unable to follow or movement is disjointed
Question 5: Your outpatient has been referred by her GP with an acute episode of vestibular neuritis that started 2 days ago. Her history is typical of a vestibular neuritis presentation.
1. Perform appropriate clearing assessment procedures.
2. Perform two (2) safe and appropriate assessment techniques that you strongly anticipate would be positive/abnormal in this patient
- VBI
- Head-Impulse test
- Dynamic Visual Acuity
- A 21 year old footballer presents with anterior knee pain while playing football.
Perform an appropriate physical examination that would help you to identify predisposing factors in a presentation of patellofemoral pain.
Predisposing factors:
Weak quads, hip abd, ER, Tight ITB, Foot pronation, Overuse, Previous knee injury, reduced ankle DF, patella maltracking
SLSquat to fatigue: Look for pelvic drop?, valgus of knee (increased femoral internal rotation)?, foot pronation?
Support maltracking to reduce symptoms
SL Hop: observe quality and sound
Step up/down b/l
Knee to wall (place measuring tape down)
Abductor (Supine), ER (Prone) HHD, Ober’s Test (Side-lying)
- A 50 year old woman presents with onset of anterior knee pain when she commenced full weight bearing 1 month ago following a fractured femur.
You have diagnosed that the patellofemoral joint is the source of her anterior knee pain.
Perform manual therapy OR adjunct treatment techniques that would be appropriate to treat likely contributing factors.
- SLS
- Ankle mobs / lnee taping
- ReAx SLS
- A 17 year old boy presents with anterior knee pain. You hypothesise that weak hip abductors and knee extensors are contributing to this condition.
Perform an appropriate physical examination that would help you confirm OR refute this hypothesis.
- Functional walk, SL hop, stair ascent/descent
- Functional SLS to fatigue
- HHD Hip Abductors
- A 16 year old boy who is currently playing in his school’s first 18 football team presents with anterior knee pain. You have confirmed that weak hip abductors are a contributing factor
Teach an appropriate exercise program that will help address weak hip abductors. Include exercise dosage and appropriate progressions.
Level 1: Side lie leg lifts: tighten bottom muscles, move one leg up inline with body, don’t let hips rotate or drop. 3 x 12 60 secs rest
Level 2: Standing resisted leg lifts. 3 x 12 60 secs rest
Level 3: Hands off support 3 x 12 60 secs rest, don’t lean
Crab walks?
- A 30 year old woman presents with anterior knee pain. She reports most pain at the end of the day or towards the end of her 10km run. This past week she found plyometric activities at the gym also flared up her pain. You hypothesise that she is not tolerating the volume of load and has a reduced capacity to tolerate peak loads.
Perform an appropriate treatment session to address your hypothesised problems.
Education:
* Understanding load Mx & modifying load (Rapid increase in activity –> Structures cannot keep up)
* Plyometrics very high imapact =, avoid for a while
* Walking –> Increase speed –> Stairs –> Running –> Plyometrics
* Manage expectation regarding rehab ie Timeframes ie 6-12 weeks strength
* Encourage active rehab (Passive can help, but requires actiev rehab from the pt
Exercises:
Crab Walks 2x15 b/l
Wall Sits 3x60 seconds –> Progress to 12 squats
Knee to wall mobs 3x20
- A 48 year old woman presents with right low neck pain, right shoulder pain and a dull ache in the lateral upper right arm.
Perform an appropriate physical examination which would help you to differentiate whether the neck or the shoulder was the predominant source of the pain.
Observe
Disrobing
Palpate Shoulder
- 4pt scap
- AC
- Humeral head
- Musculature
- Trap, Lev scap
ROM Shoulder
F/Ab/ER/IR
Special test if pain provoked
Special test
ER/Ab = empty can
IR = Lift off (Gerbers) - Belly press if unable
F = Neer’s / Hawkins Kennedy
Seated Cervical AROM + Overpressure - No overpressure if pain
E/F/Rot/LF
Prone PAIVMs
C2-7 SP
Articular pillars based on pain
Checking for pain and symptoms, ask if PAIVMs ease pain
- A 50 year old man presents with left shoulder pain. From the subjective examination you hypothesise rotator cuff tendinopathy as the primary source of symptoms.
Perform an appropriate physical examination to test your hypothesis.
Functional Ax: Taking shirt off
Standing: Palpate
RC muscles
AC joint
AROM
RC tests
Supraspinatus - Empty can
Infraspinatus - resisted ER
Subscapularis - lift-off test
Drop sign
Special test
Neers / Hawkin - Kennedy
- A 25 year man has been referred by his GP with a diagnosis of suspected anterior instability in his R shoulder.
Perform an appropriate physical examination to confirm or refute this hypothesis.
- Palpate GHJ in socket/acromion
- Tania passive range ER, feel for clunk/sliding of anterior head
- Resisted ER test Conduct:
- 20-30 degrees: Superior anterior glenohumeral ligament
- 90 degrees: middle anterior glenohumeral ligament
- Max Abduction: inferior anterior glenohumeral ligament
- AROM Abduction
- Apprehension Test + relocation test
- You have confirmed that your 35 year male patient has rotator cuff tendinopathy.
Teach an appropriate exercise management plan. Include relevant and appropriate dosage and progressions.
Scapula Setting:
1. Standing, shoulders relaxed 2. bring your shoulders back and down, as you were moving them to your back pockets. 3. Hold 3 seconds 4. Set of 20 How did that feel?
Feedback: make sure we are engaging these (point to traps)
Ask: do you have a dumbbells at home?
Start with BW first 3 days to get used to the mvmt, then add 1-2kg weight
Repeat 20 times, three times per day
- Shrugs
- Normalises upward rotation
- Perform in 30-40 degrees abduction
- Instruct “take the tip of your shoulder to the back of your ear”
○ (Tip of acromion to mastoid process) - Facilitate coordination of upward rotation muscles ie Upper trapezius at start of range, serratus and lower trapezius EOR
Build up to 20 reps once a day (when dysfunctioning), then build up to 2-3x/daily.
3 x/daily 20 reps –> weight arm in 500g increments, 3kg max
- Shoulder ER:
1. Place this band just on the edge of your shoulder
2. The band pulls your shoulder forward, and the idea is to resist this, keep your shoulder blade and humeral together
3. Use your rotator cuff muscles behind your shoulder here (point)
How did that feel?
Too hard: main part of the exercises is keeping the humeral head and shoulder together (manually guide) rather than the pulling motion at your hand so focus on that
Aim for 20:
During set: as you tire, you may feel the band to start pulling you forward, make sure you are consciously working to pull it back the entire time.
If you start to get pain, it may be because you are not pulling back hard enough.
It also works the mind-muscle coordination, so hopefully it gets easier to coordinate movements at home/work.
Progression: arm at greater abduction. 4-5 days = one set/day, then 2 sets. QUALITY OF MOVEMENT is important.
- A 45 male presents with a painful arc with R shoulder abduction. During your examination the patient specifically reports how much manual therapy treatment helped them recover from a similar previous episode of shoulder pain.
Perform an appropriate intervention for your patient.
Observation + palpation
ROM: abduction - assess scapulohumeral rhythm and identify painful arc
>Provide scapula assistance and see if that assists pain
>If so, can provide some manual therapy (massage) to release some trigger points
> Can perform some passive mobes for shoulder abduction in supine
REASSESS
Prescribe exercises -> start with shrugs
Can tape as well with axillary sling to provide support
- A 29 year old patient presents to you with confirmed anterior instability and a history of 4 prior dislocations which usually involve some sort of knock or bump to the shoulder. The most recent dislocation was 3 months ago playing footy when they landed awkwardly on an outstretched hand. During your assessment you find reduced overhead strength in all directions, especially abduction and external rotation.
Perform an appropriate intervention for your first physiotherapy session with this patient.
- Scap Setting/shrugs: 20 x 3second holds
- Band Shoulder ER (Complex) 20 reps
- Band Shoulder Abduction 2x15 reps
- Taping?
- You hypothesise that your patient may have a rotator cuff tendinopathy problem but you wish to exclude a diagnosis of adhesive capsulitis or glenohumeral joint osteoarthritis
Perform an appropriate physical examination that would help you confirm your hypothesis and differential rotator cuff related shoulder pain from adhesive capsulitis or glenohumeral joint osteoarthritis
AROM/PROM:
RC Tend: Pain ER/Overhead (Flexion/ABD) almost full ROM. Soft end-feel?
Adhesive: AROM=PROM=Empty end feel
GHJ OA: painful, restricted ROM. Hard end feel. Crepitus.
Hawkins-Kennedy (scarf) —> Rule out RC/impingement
RC: Empty can (supra), ER Test (Infra/Teres Minor), Lift-off IR (Subscap)
Adhesive:
QUESTION 1
John Brown
Your patient is a 45 year old male admitted to the intensive care unit 3 days ago with septicaemia secondary to pneumonia.
History of presenting condition: Brought in by ambulance with increased shortness of breath, rigours, tachycardia and fever. His condition deteriorated in the ED and required intubation via ETT and was transferred to ICU for further management.
Past medical history: Asthma
Social history: Lives at home with family. Works as a finance manager.
Current status:
- Intubated and ventilated via ETT
- Sedated with Midazolam, opens eyes and squeezes hand to verbal stimulus
- Continue IV ceftriaxone
- CXR: complete collapse right lower lobe. Patchy consolidation throughout right lung.
- Feeding well via NGT
- Plan: Aim to keep oxygen saturations above 95%
Task:
Perform an assessment on this patient.
LOOK: Bed lines/attachments
Patient:
Glasgow coma scale (GCS) = Eye opening, speech & motor function
Ask to open eyes
Colour, posture, wounds, breathing pattern
Monitor:
MAP & HR - pts will be on adrenaline most likely
FEEL:
Tone / movement
Squeeze hands or ask to wriggle fingers
Wiggle toes
Chest movement/expansion
Abdominal breathing - hand on belly to feel
Bibasal expansion - hands either side of lungs
DVT check
Squeeze calf, feel for temp and sweating
LISTEN:
- Auscultation
- Cough/Suction: Preoxygenate 6 breaths,
John Brown
Your patient is a 45 year old male admitted to the intensive care unit 3 days ago with septicaemia secondary to pneumonia.
History of presenting condition: Bought in by ambulance with increased shortness of breath, rigours, tachycardia and fever. His condition deteriorated in the ED and required intubation via ETT and was transferred to ICU for further management.
Past medical history: Asthma
Social history: Lives at home with family. Works as a finance manager.
Current status:
- Intubated and ventilated via ETT
- Sedated with Midazolam, opens eyes and squeezes hand to verbal stimulus
- On IV Ceftriaxone
- Feeding well via NGT
- CXR: complete collapse right lower lobe. Patchy consolidation throughout right lung.
- Auscultation: generalised decreased breath sounds to right side, coarse crackles to right upper zones anteriorly.
- Suction: Small to moderate amounts of thick creamy – yellow coloured sputum
- Plan: Aim to keep oxygen saturations above 95
Task: Perform your treatment for this patient.
- GCS: unable to respond, but will continue in the best interest of the patient
- LOOK: Vital signs, attachments, skin colour, breathing pattern
- MANUAL HYPERINFLATION
Verbalised “why we are doing it”
Verbalise “we have checked contraindications and precautions
Perform on test lungs → 3 normal 6 hyperinflated (3-2-0 tempo)
Verbalise PEEP is meant to match the ventilator, set 5 as not indicated
Monitor PIP to be less than 40 throughout manual hyperinflation technique
<Suction>
ReAx: Auscultation ESP R) LOBE AS AFFECTED
</Suction>
QUESTION 3
Christine Ng
A 45 year old female was transferred from the surgical ward to the intensive care unit yesterday evening.
History of presenting complaint: Patient presented to ED 6 days ago with severe pelvic (endometrial) pain. She had a total abdominal hysterectomy 5 days ago. Yesterday the patient deteriorated and required transfer from the surgical ward to ICU.
Past medical history: Severe endometriosis – diagnosed three months ago post laparoscopy; IV drug use; Hepatitis C; IDDM;
Current Smoker: 20-30 cigarettes / day
Current status:
Intubated and ventilated via ETT
Patient sedated with IV Midazolam and Morphine, opens eyes to verbal stimulus
Commenced enteral feeding via NG tube
Plan: Repeat CXR, sputum culture, to commence Ketamine infusion
Task: Perform your assessment on this patient.
LOOK: Bed lines/attachments
Patient:
Glasgow coma scale (GCS) = Eye opening, speech & motor function
Ask to open eyes
Colour, posture, wounds, breathing pattern
Monitor:
MAP & HR - pts will be on adrenaline most likely
FEEL:
Tone / movement
Squeeze hands or ask to wriggle fingers
Wiggle toes
Chest movement/expansion
Abdominal breathing - hand on belly to feel
Bibasal expansion - hands either side of lungs
DVT check
Squeeze calf, feel for temp and sweating
Tone / movement
Squeeze hands or ask to wriggle fingers
Wiggle toes
Chest movement/expansion
Abdominal breathing - hand on belly to feel
Bibasal expansion - hands either side of lungs
DVT check
Squeeze calf, feel for temp and sweating
LISTEN:
- Auscultation
- Cough/Suction WITH SPUTUM TRAP: Preoxygenate 6 breaths,
Christine Ng
A 45 year old female was transferred from the surgical ward to the intensive care unit yesterday evening.
History of presenting complaint: Patient presented to ED 6 days ago with severe pelvic (endometrial) pain. She had a total abdominal hysterectomy 5 days ago. Yesterday the patient deteriorated and required transfer from the surgical ward to ICU.
Past medical history: Severe endometriosis – diagnosed three months ago post laparoscopy; IV drug use; Hepatitis C; IDDM;
Current Smoker: 20-30 cigarettes / day
Current status:
- Patient sedated with IV Midazolam and Morphine, opens eyes to verbal stimulus
- Intubated and ventilated via ETT
- Commenced enteral feeding via NG tube
- CXR: R lower lobe consolidation with underlying collapse
- Auscultation: Decreased breath sounds to right lower zone
- Suction: large amounts of thick yellow coloured sputum
Plan: Repeat CXR, sputum culture, to commence Ketamine infusion
Task: Perform your treatment for this patient.
- GCS: unable to respond, but will continue in the best interest of the patient
- LOOK: Vital signs, attachments, skin colour, breathing pattern
- MANUAL HYPERINFLATION
Verbalised “why we are doing it”
Verbalise “we have checked contraindications and precautions
Perform on test lungs → 3 normal 6 hyperinflated (3-2-0 tempo)
Verbalise PEEP is meant to match the ventilator, set 5 as not indicated
Monitor PIP to be less than 40 throughout manual hyperinflation technique
<Suction W/ SPUTUM TRAP>
ReAx: Auscultation
Kamal D’Souza
A 31 year old male admitted to intensive care unit 2 days ago post motor vehicle accident (MVA).
History of presenting complaint: A 31 year old male presented to ED post MVA. He sustained the following injuries:
- Fracture R femoral shaft
- Splenic tear as shown on abdominal ultrasound
- R lung contusion
- R pneumothorax
Past medical history: Asthma
Current status:
- Intubated and ventilated via ETT
- IM nail insertion by orthopaedic team 2/7 ago to manage the fracture R femoral shaft. Post operation orders: NWB for 6/52
- Repair of spleen by general surgical team 2/7 ago
- UWSD inserted to drain R) pneumothorax. Large amount of bubbling noted on UWSD
- Sedated with Midazolam, morphine given as pain relief
- Continue NG feeds and maintain fluids
- Aim for MAP > 65, requiring Noradrenaline to achieve this
- Daily CXR
Task:
Perform your assessment on this patient
LOOK
FEEL
LISTEN: NWB thus do not roll for back auscultation
Suction: before suction, verbalise that you have considered lung contusion and that we will be safe and careful with suctioning to prevent complications post MVA
