CCA Support workbook

Contents
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. What are the assessors looking for? Criteria and grade descriptors 4 Developing your case history taking skills 7 Tips on Case presentations 9 Tips on how to structure your first CCA discussion 11 (Hypothesis formation and examination proposals) Suggestions for Patient examination routine 15 Tips on how to structure your Second CCA discussion 19 (Evaluation, Treatment plan and patient management) Tips on management of your on-going patient 22 Common Conditions 24 Typical CCA style questions and scenarios 25 Anonymous student feedback from previous 26 support clinics Feedback sheet case history skills 45 Considerations to help you focus on clinical 47 reasoning (11 points) NP clinic feedback sheet 48

1/What are the assessors looking for? Criteria and grade descriptors
During your CCAs you are examined by one internal and one external assessor. These assessors work independently within their pairs and have a moderator overseeing the process. All the assessors are marking to the same criteria and using the same grade descriptors. The CCA is assessed at M level so please familiarise yourselves with the M level descriptors i.e. self -reliant, autonomous practitioners who are comfortable with uncertainty. Assessors pay particular attention to the following areas: Case history taking: The assessors will sample parts of the case history. This is your opportunity to demonstrate your communication skills, differential diagnostic thinking and clinical curiosity. Marks are awarded for: Rapport, eye contact, putting patient at ease etc Questioning and listening skills - Open v closed questions for example Following up leads - actively searching for diagnostically useful information Timekeeping.

Students commonly lose marks at this stage by Labouring over irrelevant questioning and poor timekeeping Inappropriate questioning, leading questions Poor listening skills - losing focus - repeating questions Omitting to follow up on useful leads - lack of curiosity Inaccuracies in recording of information.

A poor case history will impact on the whole performance. Case presentation: The assessors are hoping to hear a succinct account of the salient features of the case. A good case presentation should take no more than a few minutes and the more complete is it the less clarifying questions will need to be asked. Jumbled presentations where the assessor has to ask a lot of clarifying questions will lose marks. Hypothesis formation: The first discussion is your opportunity to demonstrate your clinical reasoning and clinical decision making. You can also demonstrate underpinning core knowledge and how you prioritise your ideas. Plan this out carefully and have a structure. If this goes well it gives your assessors a good impression. Make sure that you have evidence for all your ideas from the case history and address all the presenting symptoms. Jumbled
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hypotheses that lack justification lose marks. Plucking unlikely ideas/pathologies out of the air with no justification can mystify your assessors and invite further questioning. Examination proposals: Briefly discussing your examination proposals and the order of your examination gives the assessors an insight into how you prioritise your ideas. You have the opportunity to demonstrate why you might do clinical screening and address any concerns in the case history. Examination skills: This is your opportunity to demonstrate your observational skills, postural analysis, patient handling, active, passive and active resisted testing, orthopaedic testing, clinical screening etc. The assessors are looking for a structured, organised fluent examination routine taking into account patient comfort at all times. The more complete the examination the more marks you will get. However be careful of going off and conducting superfluous testing which will waste time and not gain marks. Ensure that everything you do is relevant and tailored to the presentation. Interpretation of clinical findings: This is your opportunity to critically evaluate the relevance of your clinical findings in the context of the presentation and the patient morphology etc. Remember that a list of clinical findings is not an evaluation! Evaluation Skills: This is your opportunity to demonstrate your understanding of what is happening locally in the symptomatic area and integrate this into a more global evaluation, taking into account the predisposing and maintaining factors, barriers to recovery etc. It is also where you can demonstrate your application of osteopathic concepts. Take some time to write up a summary of dysfunction before your second discussion. Treatment plan and management: The assessors will be interested in how you propose to treat and manage the patient including appropriate use of techniques, advice, modifications, etc Treatment: Try to demonstrate a varied repertoire of techniques. The assessors will be interested in your patient handling, choice of techniques, operator posture, etc. A brief description of the grade descriptors are as follows: A grade - fully achieves the learning outcomes. Consistently excellent work throughout the process. B grade - Ably achieves the learning outcomes with some minor defects. Very good work. C grade - Sound performance with some omissions. D grade - Adequate work with significant defects or omissions.
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E grade - Inadequate work with serious omissions that impact on overall performance. F grade - Work of very little merit or no submission. G grade failure on grounds of safety. Please bear in mind that your CCA grade is based on a snapshot performance within that session and it will reflect the level of competence you have demonstrated to your assessors in that time frame. The assessors do not know what is going on in your mind so you must make it explicit to them what you are thinking and why. Think about the M level descriptors! Assessors may sometimes ask you clarifying questions if they are unsure of your thought processes. They may also ask you extending questions to give you an opportunity to achieve a higher grade or to meet other criteria that you havent been able to demonstrate with the patient.

2/Developing your Case History Taking Skills

During the case history taking, your assessors will be popping in and out of the room sampling parts of the interview. If you find this unsettling try positioning your chair and the patients chair so that you are out of the line of sight of the assessors. This way you may hear them coming and going but you can keep focused on the patient. Some assessors like to come in at the beginning of the case history to hear the patients complaint and some like to hear the systemic questioning as you will be presenting the symptoms to them later anyway. Some assessors may come in more than once to see how you are getting on for their own timekeeping purposes. The assessors will be looking at how you engage with the patient e.g. rapport, eye contact, listening skills etc as well as your questioning routine (a good mixture of open versus closed questions). They are interested in your clinical curiosity and whether you follow up leads and explore ideas. They are hoping that you will establish a timeline/chronology of events and link the information together. If a patient has more than one complaint they are hoping that you will try to link them together or separate them out in terms of onset etc. A good case history will be a balance between the patients agenda and the practitioner agenda. Ideally the patient will feel listened to and have an opportunity to tell their story. Alongside this the practitioner will have enough diagnostically useful information to generate several hypotheses. Timekeeping needs to be managed well and various strategies used depending on the patient responses. If the patient is a poor witness or unreliable or has language problems etc the assessors will understand. It may be that you would have to rely on your examination findings if you are unable to collect sufficient information in the history.

The Patients Agenda I have a Pain/stiffness/ symptoms

The Practitioners Agenda Try to understand the Patients Agenda via the case history, body language, patient demeanour, responses. What do I need to know to help this patient? What information would be diagnostically useful?

Whats wrong with me?

Fear- loss agency, disability.

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Concerns- impact on lifestyle. Anxiety- Will it get better? Expectations- What TTT? Advice? Outcome? What will happen?

Can I address the patient concerns? Am I able to make a prognosis? Can I treat/manage this patient? Can I manage patient expectations?

In the 2nd and early 3rd year, the case history is often done by rote. In 3rd and progression into the 4th year, there should be more integration of core knowledge underpinning the case history and the case history should follow the patients narrative if possible. To address the practitioners agenda we need to switch the way we think about the case history and work backwards from the hypothesis. Try to think about possible differentials early on during the case history and actively search for diagnostically useful information in order to gather evidence for the hypotheses

3/CASE PRESENTATION
Case presentation is a very important skill in your clinical and professional development and is an important aspect of the CCA process. A SUCCINT and CLEAR case presentation addressing all the SALIENT features will impress your examiners and be time efficient during the process too. A good case presentation is not a read through verbatim of the case history. It is a prcis of the data you have captured. You do not have to discuss your thoughts or opinions during the case presentation as you may lose focus you are simply presenting the factual data from the patient interview. (You can subsequently discuss your ideas /opinions during the hypothesis formation). Example of a typical case presentation Mrs X is a 66 year old retired cleaner who presents today with a 20 year history of low back pain. The symptoms consist of an intermittent ache in the left lower lumbar spine which can radiate to the left buttock with occasional paraesthesia in the left lateral thigh as far as the knee. There are no other motor or sensory disturbances. The ache is aggravated by prolonged sitting of more than 30 minutes and repetitive bending which will provoke the radiations of symptoms into the thigh. The symptoms are relieved by gentle movement, walking and lying down. Sleep is not disturbed. She is taking Neurofen as required for the symptoms which help. The symptoms are of a chronically relapsing nature with approximately 2- 3 attacks per year. These attacks are triggered by lifting or bending and usually resolve within 2 weeks. The first episode occurred after the birth of her third child at the end of a difficult labour which resulted in a caesarean section. She feels that her low back remained weak afterwards and has never fully recovered since. This current episode came on one month ago after gardening and is the most severe and lasting bout of symptoms so far and has led to the patient seeking advice for the first time. No previous advice or investigations have been sought.
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Mrs X is currently being treated and managed for hypertension which was diagnosed last year. She takes X and her BP is currently Y. She has 3 monthly check-ups. Otherwise she appears to be systemically well and enjoying retirement. There are no obvious concerns in this patients medical history. Mrs X enjoys line dancing 2 x weekly, gardening and looking after her grandchildren. She feels that her problem is due to wear and tear and puts her pain at 4/10 on the pain scale. She is concerned that the problem will get worse with age and interfere with her plans. After the presentation the assessor may ask some clarifying questions or extending questions or they may be happy for you to proceed at this point if the presentation is comprehensive.

4/Tips on How to Structure your First CCA Discussion, Hypothesis Formation and Examination Proposals
After the case presentation try rounding up your patient and briefly discuss your impression of the patient e.g. This is a young, healthy patient with no systemic concerns who has injured their ankle or This is an anxious patient who is concerned that their problem will impact their job etc. Then move straight on to discuss your hypotheses. Once you have completed your case history you will hopefully have enough information to generate several appropriate hypotheses for your patient. After you have presented the case to the assessor go straight on and discuss your ideas. It is very useful at this stage to have some structure to your hypotheses and how you present your information is very important. This is a key part of the CCA process where you have an opportunity to demonstrate your clinical reasoning and clinical decision making. They will be assessing how you interpret the data and integrate it with your core knowledge. Tips for your hypothesis formation DO use your thinking time before the first discussion to prepare your ideas and try to make some notes on how you plan to present. This may be bullet points, a time line, a mind map etc. FIRST - USE VINDICATER This helps you to think laterally and sift the evidence you have.
V isceral /vascular ( do you have possibility of visceral referral?) Infective Neoplastic (Is there history of infection, high temp, malaise, night sweats?) (Constant symptoms for NAR ? Previous history C/A?)

Degenerative (Age, history of trauma, repetitive use/overuse?) Inflammatory (Daily pattern , worse in morning several hours and at night?) Congenital/developmental (onset in teens , relapsing?)
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Auto immune (Inflammatory picture, bilateral symptoms, skin conditions?) Trauma Endocrine (diabetic neuropathy)

Rheumatology (polyarthalgia, bilateral, inflammatory) The sieve may help you to identify issues for discussion.

1/ MAKE IT EXPLICIT TO YOUR EXAMINER THAT THE PRESENTATION IS APPROPRIATE FOR YOU AS AN OSTEOPATH. (This decision may have happened in your head but you need to demonstrate it to the assessors!) Do you have evidence in the case history for a Musculo-skeletal presentation or not? If you think the symptoms are M-SK in origin? Can you support this with evidence? Intermittent? Activity related? Clear mode of onset? Positional factors? Aggravating factors? Position of ease? Systemically well? If the evidence points towards a musculo- skeletal presentation, then.. 2/WHAT STRUCTURES DO YOU THINK COULD BE IMPLICATED? e.g. lumbar spine, Hip, SIJ. Refer to the location/distribution of symptoms and the aggravating factors. Think bio- mechanically and apply your knowledge of anatomy and work out which gross structures may be involved. 3/WHAT TISSUES COULD BE IMPLICATED? e.g. Muscle, disc, facet, ligament articular cartilage, bone, capsule etc Use your knowledge of tissue behaviour and your aggravating/relieving factors to help you. Muscles can be symptomatic on initiation of movement and are involved in protection for any injury. They will be implicated on any active movement or active resisted movement. Ligaments can be symptomatic when they are at the end of their range or on prolonged stretch. Joints can be symptomatic on weightbearing and approximation/ compression. Discs can be symptomatic on weightbearing and torsion. Capsules are sensitive to stretch etc
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If you think the presentation is non musculo skeletal? What are your concerns? Do you have worrying evidence? E.g. Constant symptoms? NAR for onset? progressive symptoms? No relieving factors? Other systemic concerns? Do you need to consider clinical screening for the patient? If so what body systems do you need to examine? Do you need to consider referral for your patient? Overall is your patient stable enough to examine? Does your patient have a mixed presentation? i.e. some evidence of M-SK involvement and some systemic issues concurrently? How will you proceed? Often our patients have on-going systemic issues that we need to consider in our management and how they may affect treatment. Discuss any that you have identified. 4/PRIORITISE YOUR IDEAS Most Likely to least likely? e.g. A 40 year old patient with a 20 year history of headaches which have not changed in character is unlikely to have a sinister cause. However a 40 year old patient who has had a 20 year history of headaches which have recently become constant and changed in nature along with changes to special senses could have a sinister cause. Bio- Psycho-Social Elements/Lifestyle/Leisure. If you have identified any issues here that may affect your treatment management or prognosis of the patient discuss them with your assessors. It demonstrates to them that you are using your concepts and thinking holistically. 5/YOUR EXAMINATION PROPOSALS Once you have generated your ideas discuss how you propose to take the examination forward and test out your hypotheses. Write down the order of your exam as you may need to test out your hypotheses in a different order at this point. E.g. if fracture was on your list of differentials but very unlikely it is still something you would test for first in your exam. Remember this is YOUR patient and YOU are in charge. By taking control of this discussion you demonstrate M level performance.
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5/Suggestions for Patient Examination Routine Standing Examination

OBSERVATIONS: Dont forget to look all around the patient - not just at their back! Look for skin colour, trophic changes, nails, varicosities, balance, tremors, morphology etc If patient reports a problem with gait this may be a good time to assess it. POSTURAL ANALYSIS Dont forget to start with weightbearing- is it left or right in the lateral plane? Anterior or posterior in the AP plane? Look for asymmetry in muscle bulk tone etc Does the patient have a protective posture? Are they leaning into or away from the pain? Check pelvic levels - Dont forget all points ( ASIS, iliac crest and PSIS). Is the pelvis asymmetrical or rotated? Assess the AP posture not forgetting the front of the body. (Think about the aggravating factors in the history: is the patient having difficulty with AP manoeuvres eg sitting, flexing etc?) Assess the Lateral curves. Is there a scoliosis? Why is it there? Can you account for it? You may need to investigate it further on sitting and lying? Is it structural or functional? Assess the orientation of the limbs in relation to the body especially if the symptoms are in a peripheral joint. Palpate tissue bulk, tone etc as appropriate This may be a good time to assess pelvic movement and do tests such as Stork, Sift, Trendelenbergs etc ACTIVE MOVEMENTS In each direction you are assessing overall range of movement and quality - observe where they get their movement from? Which areas do not participate ? Is anything limiting that movement? Any difficulty initiating a movement? Are they limited by pain? Stiffness? Where? Do the movements reproduce any symptoms? Do they feel that they cant go further? Ask the patient!!
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NB/ Always consider examining the joints above and below in peripheral joint presentations. Remember to do ACTIVE HIP, Knee and Ankle if assessing the lower limb. These are often omitted and marks lost! Similarly with the upper limb dont forget active elbow and wrist etc. SITTING EXAMINATION Never skip this out especially if sitting is an aggravating factor. Only omit this if the patient is acute and cant sit down. Observe how comfortable the patient is whilst sitting. How do they adapt to this change of position? How do the AP curves change if at all? What happens to the lateral curves? Do they change? Can you decide now if there are functional or structural changes? This would be the best position to assess active movements of the cervical spine and shoulder girdle, elbow and wrist Assess the thorax, ribs, thoracic inlet etc. Any other tests that may be appropriate eg cranial nerves, CVS Resp, Adsons, Lymph etc RECUMBENT EXAMINATION Be aware of patient positioning- check that the patient can lie down and support with pillows or raise head end if necessary especially in the elderly (dizzynesss, vertigo etc) NB/ If the patient is acute get them sidelying straight away with the painful side uppermost. Observe how the patient adapts to lying down - can their spine flatten out onto the plinth? Is the lumbar lordosis maintained? Use the supine position to assess cervical spine, upper and lower limbs, SIJs Check leg lengths and rotation through the limbs. PASSIVE SEGMENTAL EXAMINATION Palpate the fascia and deeper muscles once off weight bearing. Remember to conduct a complete passive examination in all ranges looking for: Range of movement in the segments Direction of movement - joint ease/joint bind Quality of movement End point Limitations to movement.
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OTHER ISSUES Patient comfort: Ask if they are comfortable or have difficulty with any position Never put an acute patient prone or keep a patient prone for too long as they may have difficulty getting up again! If a patient is lying prone check what is happening to their head and neck? Do you need to pad them out with pillows? Watch your own posture and use the plinth well If the patient is acute do all your examining sidelying with the painful side uppermost. Do all you tests in the same position eg SLR, Reflexes etc. With peripheral joints always look at the joints above and below With shoulder presentations always look at the neck, T spine, Scapula humeral joint, AC joint and SC joint as well as the GH joint! IN SUMMARY By the time you have finished your examination you should have: A good appreciation of how the body has adapted to its environment and whether these compensations are symptomatic What is happening on a local symptomatic level A good understanding of whether the patients problem is predominantly in the AP or lateral plane or both. Whether the patient has structural or functional changes Any predisposing and maintaining factors that may affect your prognosis.

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6/ Tips on How to Structure your Second CCA Discussion, Evaluation, Treatment Plan and Patient Management
After you have completed your examination of the patient and recorded your clinical findings you will have a second discussion with your assessors. Before meeting up with them again take some time to organise your thoughts. This is another KEY part of the process. The assessors are looking to see how you: INTERPRET THE CLINICAL FINDINGS ARRIVE AT YOUR WORKING DIAGNOSIS/EVALUATION YOUR IDEAS ON TREATMENT AND MANAGEMENT YOUR IDEAS ON PROGNOSIS.

It is very important at this stage that you are in control of the situation and demonstrate M level autonomy. The assessors are not your tutors so do not look to them to draw the information out. NB /Historically Students often start the 2nd discussion by listing all their clinical findings and somehow run out of steam/ confidence before they get to the evaluation. The examiner is then left to draw out the evaluation with some prompting and this will lower your grade. If you get nervous at this stage it may be a good strategy to write up your summary of dysfunction before the discussion. You can then start by discussing your evaluation and then use the evidence from your examination to support it. This will also save you time and you will get marks for reaching a conclusion! TELL YOUR EXAMINER WHAT YOU THINK IS GOING ON WITH YOUR PATIENT! PATIENT EVALUATION In your evaluation/ summary of the patient try to include the following: 1/ What structures/ tissues/ pathology in your opinion is causing the local symptoms? (At this stage you will have tested out your hypotheses and hopefully been able to reproduce the symptoms or recreate the situation that brings on the symptoms. You will have the aggravating factors/ symptom behaviour from page 1 of the history and will be able to recreate these situations in the examination). 2/ Why have these areas become symptomatic? (Was there a clear mode of onset with trauma? or is it a breakdown in compensation with other issues? or age related etc.).
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3/ What are the PDFs? (Are there postural stresses on the symptomatic area? Congenital/developmental issues? Any pre- existing problems?) 4/ What are the MFs? (What is happening in the patients life to maintain the symptoms e.g. Work, lifestyle, Sport, Psycho- social? Flags? Barriers to recovery?) 5/ Any other issues? (You will get more marks for knowledge and application of your concepts and principles!). After you have discussed your evaluation go straight on and TELL YOUR EXAMINER WHAT YOU PROPOSE TO DO. TREATMENT PLAN Short term what do you propose to do to help the patient symptomatically? What techniques will you use? Do you need to adapt/ modify your treatment in any way? Are there any contra indications/precautions? What advice will you give the patient? Long Term what do you hope to achieve globally with the patient? How will you achieve it? Treatment? Exercises? Diet? etc. How realistic is your treatment plan? After discussing your treatment plan, discuss what you think the outcome will be. Your examiners will be impressed if you have tried to anticipate the outcome! PROGNOSIS Think about the ideal outcome for your patient where they are symptom free and have full function. Is this realistic in this case? What aspects of the problem do you think you can improve? Symptoms or function or both? How long do you think it might take to achieve your treatment aims? If you have a traumatic injury you need to know the healing times for different tissues. What factors are working against you and the patient in this scenario? What PDF and MF can be changed? How compliant is the patient? Do you think this patient can ever be symptom free? Do you think their problem will relapse? Prognosis = Ideal outcome ( PDF + MF). Does it help to think this way? Failure of adaptation?

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7/Tips on management of your on-going patient

Your on-going patient is your opportunity to demonstrate your treatment and management abilities that may not have been assessed with your NPs. If this interaction goes well it can really make a difference to your grade especially if you have had inconsistent performances with your NPs. However the assessors take a poor view of a situation where there is very little understanding of the problem or very poor monitoring of any systemic issues. You will get marks for the following areas: A good understanding of your patient locally and globally. Your ability to perform an appropriate varied selection of techniques Patient comfort and operator posture throughout. Strategies for short medium and long term management Advice given to patient e.g. exx, contrast bathing etc How you have assessed patient progress both subjectively and objectively. How you have tracked and monitored any on-going health issues. e.g. BP Any background core knowledge that is relevant to the patient presentation. Communication and rapport- level of continuity with the patient Established a patient partnership- consent issues

TIPS Try to develop your skills in being able to treat and talk at the same time! Have hand-outs or instructions for patients typed up. Make sure you can discuss patient progress in terms of symptoms, function, and objective changes. Make sure the case notes are complete as the assessors often refer to them if in doubt. Make sure any neurological deficit has been monitored. Have any previous letters of referral or communication ready for assessors to read. It is often difficult to get patients to come in for CCAs. Over the next few weeks treat every NP as a potential CCA RP patient.
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8/Common Conditions

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9/Typical CCA style questions and scenarios

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10/Anonymous student feedback from previous support clinics

In this section you will find 4 examples of detailed feedback given to students in previous support clinics. Try reading the case presentation and making your own hypotheses before reading on further. Ask yourself if there is enough detail to make a hypothesis. Then read the feedback comments and hopefully this will give you an insight to what the assessor is thinking at each stage.

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Scenario1
This is a NP completed in support clinic. The patient information presented by the student has been recorded verbatim and the feedback is given at each stage of the process. Case presentation

31 year old male. Sound editor. Sedentary for last 5 years. PPW: 1/ Left sided chest pain. Diagnosed by GP as costo-chondritis.

Onset 1 week ago - no specific onset. Improving. Now also some discomfort in upper T spine. Agg: by coughing, breathing, sneezing Rel: stretching chest 2/ Weakness in both hands right > left. No P and N but some numbness? Onset 1 year ago NAR. Fluctuating. Overall progressing. Agg: extension C spine? Sleeping? FH: of C/A, Diabetes and CVS problems.

HYPOTHESES 1 Costochondritis 2 CVS 3 TOS 4 C5/T1 Radial Nerve?

Feedback. The case presentation lacked detail. How the GP had arrived at his diagnosis of costochondritis was not clear. The onset was unclear maybe you could have followed up on the patients gym sessions and find out what he had been doing prior to the onset. (He clearly had some mechanical agg factors in the history). As the primary presentation was chest pain and there was a FH of CVS problems it would have been prudent to follow up on this and explicitly demonstrate to me that you had asked these questions to see if the chest pain was activity related.

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Regarding the weakness in the hands I was unsure of the distribution on the symptoms and when and how they came on. Did C spine or shoulder movements affect the hands at all? It appeared to be sleep related but there was no exploration of sleeping position, change of bed, pillows etc. You stated that it was progressive but did not clarify how? Was it becoming more frequent? More severe? Had the patient had any investigations for it? Any previous history of either problem? Any previous traumas that may predispose him to early degen changes in the C Spine? Was there a DP to the problems? (Looking for inflammatory pattern?) Did you attempt to link them together? Systemically (when prompted) you had asked about palpitations and SOB but did not make this clear in the discussion or link it to the presentation. Your hypotheses for the chest pain were limited to costochondritis and CVS. Did you consider any respiratory causes for the chest pain? What kind of conditions might present as sudden onset of chest pain in young male? Be careful of being influenced by the GPs diagnosis especially as we had no information about how he arrived at that conclusion. Make your own clinical decisions based on your own evidence and findings. At this point you had no evidence to support costochondritis in your own case history. Would you have considered this as a hypothesis if the patient had not mentioned it? However you did have some clear evidence in the history of Rib and T spine dysfunction but this did not appear in your hypotheses. You did not explicitly discuss potential CVS issues with me until I prompted you. It may have been considered in your head but you did not talk about it!! Differentiating between CVS/Resp and MSK would be a priority here. Be careful of making statements like Ill check his BP to make sure there are no CVS problems. Would taking a patients resting BP reassure us that he doesnt have angina? Would a full CVS/Resp exam reassure us? Would more careful questioning in the case history combined with thorough clinical screening be more reassuring? Your hypotheses for the bilat weakness? P and N? Numbness? were very vague. You did not explicitly seem to consider the implications of the bilateral nature of the symptoms, which could generate several differentials. You mentioned TOS but not how this might cause the symptoms. You also mentioned radial nerve involvement but not how it might be affected and where. You did not enquire about symptoms in the lower extremity? This was a missed opportunity to demonstrate your core knowledge of anatomy and neurology. Examination I did not witness the examination due to time constraints with the other students. Evaluation When I asked you to discuss your evaluation of the patient you presented a list of what appeared to be random clinical findings as follows: Active SB and Ext Left reproduced pain over rib 6 on left.( was it T sp or C sp?) 1st rib was restricted (How? ) Neurological testing (upper extremities only) was normal. Adsons test was negative ( Bilat?) Passive SB and Ext of C1/2 reproduced pain in the left upper extremity. (where?)
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BP 120/70.

( no other CVS or resp screening).

Working diagnosis when prompted was costochondritis. The bilat upper extremity symptoms were not accounted for.

I was mystified how this collection of findings led you to that conclusion? From the discussion it was apparent that you did not do a full CVS or Resp exam (only the BP). You did not consider neurological screening for Lower extremities. We discussed why this might be a good idea in view of the bilat upper ext symptoms?? You did not describe the patient posture (AP or Lat) or try to link the symptoms to patient work or leisure activities. After some discussion you decided that there was a rib 6 lesion and treated it with HVT. The ttt and management plan was superficial and needs some review, as does the working diagnosis. ACTION PLAN Follow up leads in Case history. More clinical curiosity. Actively search for more diagnostically useful information during the Case History. Try to think of your differentials at this stage. Use your vindicater when sifting the information Support your hypotheses with evidence from the CH. Discuss any potential systemic concerns and any plans for clinical screening. Make sure there are no omissions in the examination. Have structure and order to exam. Interpret the clinical findings to reach an evaluation. Consider the local evaluation and the bigger picture. PDF and MF. Have a pertinent ttt plan and ideas for management.

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Scenario 2 Case presentation This is the information you presented to me 69 year old female patient. Retired housing officer and previously a district nurse. PPW Right low back/hip pain some radiations into posterior right thigh and occasionally left flank. No Pand N Numb weak etc. Onset 15 years ago -Always saw Mr Bruggemeyer - Osteo TTT helped. -Been self- managing low back pain for last 9/12 via Ex and stretching. Pain has increased since recent cough increase pain on right low back. Pt very body aware does Yoga, Knee hugs and L sp Rotation exxx . Saw GP 2 years ago re low back pain and pxx NSAIDS and omeprazole. Pt also had increase urgency in urination over last 9/12 but has noticed it is due to increased water intake. (No Nocturia). No pain or difficulty stopping starting. AGG: Extending L sp when standing, up from low seat, sitting on R buttock, Flexion hips. REL: 2 paracetomol and massage, Ice/cold, pillow between knees. N/A Valsalva Yoga bridge, flexion. Also has history of chronic bilateral knee pain. L > R . Has to go down stairs sideways.Pt thinks it s O/A? GH: good . Sleep 8 hours per night. 14 st ( K ) . 59. High cholesterol? controlled by diet. Childhood asthma. Bronchitis. 3 years ago cataracts both eyes. Menopause at 56 and HRT 5 children all born before the age of 23. Then sterilisation. Feedback
Overall this presentation lacked some details and would invite several questions from the examiners. This lady obviously had all her children very young and presumably then went on to train as district nurse? I would be interested in approx how many years she spent doing that as it involves a lot of bending lifting and often in an environment not conducive to good ergonomics etc. Did she move to housing officer job because of her back? How many years of sedentary work did she do? Did it link in with her back pain?
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Did we have an onset for the low back pain? She says she had it forever? I would be interested to know if she had any problems during the pregnancies or births as they were so close together? Or was there a specific incident that triggered it initially? I would be interested in the behaviour / pattern of the low back pain over the years ie how frequent/Severe the episodes were, what triggered them and how long they lasted etc. Also did she ever have imaging? X rays? We know she responded well to ttt. What did she have done? We know that this lady had increased urination which appeared to coincide with the worsening of the low back pain. You established that it was due to increase water intake? Did you ask why she was drinking more? Thirst? Diabetes? We also know that this lady had a history of childhood asthma and bronchitis but no details of how this affected her or when it was diagnosed ot ttt? ? She mentioned that her back had got worse with a recent cough? What was the status of this cough now? Was it investigated? Did we know what her cholesterol was? Levels? Was it being monitored? We did not have any details for the knees apart from the fact that she was unable to go down stairs. Onset for the knees? Linked with low back pain or separate problem? Any other joint problems as knee pain was bilateral? Any investigations? Diagnosis for knees? HYPOTHESES These were your hypotheses You presented a good clinical temporal profile for this patient. Chronic focal progressive etc. You decided it was MSK in nature. Good to make this explicit to examiners. You verbalised your ideas very well. You decided that there were no systemic concerns. Im not sure that you could justify this on the level of detail you presented. If you followed up all your leads in the history and they were negative you would have more justification for this statement. Structures considered: lumbar spine, SIJ, Hips Possible disc involvement. When prompted you talked about degeneration. Knees were not considered. Examination Proposals Pin Prick, Vibration, Reflexes Standing exam SLRT Slump T spine.
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Feedback You started well with the CTP and could verbalise your ideas concisely. It is good to make it explicit to the examiners that you think it is MSK problem and you need to justify this with evidence from the history. Regarding the no systemic concerns I think you would need to provide more evidence before the examiners would be satisfied with that statement. You would need to reassure them that you had followed up on the cough, bronchitis, urination cholesterol etc to support your statement. They would want to know how you arrived at that decision; otherwise it looks like you have made assumptions about the patient. You have considered some structures in your hypothesis.( L sp SIJ and HIP) You had quite a lot of evidence that the L sp was involved but not many agg factors to support your SIJ or hip. You could have asked about more activities that would involve the hip and SI . You did not really discuss your differentials for the post thigh pain? The examiners would want to know if you thought it was referred? NRC? etc try to give more details about the character of the pain i.e. diffuse linear? And your thoughts on when and what may cause it? When was the thigh pain present? You did not discuss the knees although the patient seemed to be quite disabled with them. Now, you may not be able to evaluate everything in the time allowed but the examiners would expect you to have a few ideas for the knees and maybe consider how they contribute to the overall postural picture etc. you could then look at them in more detail in subsequent visits. They would be looking to see how you prioritise. You mentioned that the discs may be involved and when prompted you talked about degeneration of the discs which was highly likely. Try to put your hypothesis into context for the patient age and situation. Think about the stage of discal pathology you may expect in a patient this age with this history. You exam proposals suggested to me that you were looking for a discal protrusion and NRC. I was wondering Would a slump test be positive on a degenerative discal picture? You did not explain why you were doing these tests ie you didnt mention the L/Ext pain in your differentials but then you were testing for it? SLRT is for stretching the Nerve roots. I presume you were considering NRC and if so did you have evidence in the history / differentials that the post thigh pain may be neurological in nature? Try to link your line of thought/ reasoning together and demonstrate this to the examiners. Patient Examination I missed this due to other time constraints with other patients Evaluation Degeneration /disc bulge/protrusion in multiple levels of lumbar spine L2/3/4. Supporting evidence/ clinical findings Very poor mobility lumbar spine, all movements came from hips very good ROM active and passive
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Pain on return from flexion? In L SP? TTP over L 234. Positive slump test? Positive SLR? reproduced pain in RSIJ and ischial tuberosity? Pain over right SI on compression, relieved by traction.? Neuro testing pin prick Pand E reflexes decreased bilat, vibration decreased?

Feedback Your evaluation of degenerative lumbar spine sounded feasible for this patient but you need to provide more supporting evidence in your exam. I was confused about your interpretation of the slump and SLR for this lady. I didnt see you do it so I cant comment on whether your interpretations were correct. You need to be clear what you are looking for in the SLR. Yes it is good to report what happened but was this a positive result? If so you would be considering a NRC in your evaluation? Similarly with the slump test. Would you expect an elderly lady with degenerative spine to have a positive slump? What other reasons could there be for her to have pain on sitting/ slumping? You mentioned that she had a very rigid lumbar spine? May be it could not adapt to sitting very well? You did not describe to me what happened on sitting exam? Or on the passive exam? What would a spondylotic lumbar spine feel like on passive analysis? I was unsure what you meant by SI compression and traction? Was this significant? What was the mobility like in the SIJs? Did you have findings for the TSP? Knees? TTT plan Gentle artic Lumbar spine and ST LES and QL This was the first time you mentioned QL? What was going on with it? What was the aim of ttt? No long term TT plan discussed due to time Overall This was an adequate performance but you missed a lot of opportunity for more marks . You did nothing unsafe or incompetent. You have a nice manner with patients and are good at verbalising your ideas. You appear to be a confident and mature practitioner and have good pt handling skills However to improve your grade you need to follow up leads on the case history and/or demonstrate that you have done so. Your hypotheses and evaluation need more supporting evidence and you need to be clear about your interpretation of tests. Overall more details.

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Scenario 3 Case presentation This is the information you presented to me: 38-year-old male. Lab worker. On feet and some manual and 2 hours per day on computer. PPW: Intermittent low back pain on Right. Onset: 2o years ago. Episodic since then. Approx. 3 episodes per month lasting from 2-7 days. Attacks triggered by minor movements or wakes up with it. Most recent episode was 1 week ago. Pt had a single episode of posterior thigh pain on the right. No Pand N , Numb or weakness. AGG: Flexion, turn in bed, Cross legs, Right hip flexion. REL: Rest, Massage,NSAIgel. No night pain or night sweats. Systemic Patient diagnosed with epilepsy/ depression/cluster headaches. Last seizure was 3/52 ago. Cluster headaches occur 1-2 x year and last for 3 weeks. Meds: Citalopram, Anti-epileptics. Appetite decreased? Weight loss? (dropped 2 clothing sizes?) stressed? Gets stomach pain before eating? Has looser stools? Increase frequency? No blood in stools. Occasional tightness in chest. No pain on exertion. But some SOB. Smokes 10-15 per day. No BP check. Gets dizzy when standing? Postural hypotension? Pt has psoriasis. Decreased frequency of micturition. Doesnt feel need to pass water. little and often. Had cyst removed from testicle. FH paternal C/A, Mother hypothyroid.

Feedback You gave me a succinct presentation but some details were lacking. This left me with a lot of questions that I would want to ask to see if you had followed up all the leads on the patient. Eg regarding the presenting complaint:
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was there an initial onset at the age of 18 ? Triggering event? How has the patient managed the considerable number of attacks so far? Why has he sought advice for this one? Has he ever had any investigations or ttt ? X rays or scans? Are the attacks changing in nature? More frequent or more severe? Has he ever had lower extremity symptoms before? Was the pain always on the right? Any joint aches and pains elsewhere? (bearing in mind the psoriasis?) Any daily pattern? Inflammatory picture? Systemic questions How long had patient had epilepsy? ( we later established since age 2). How long had this patient been medicated for it? ( Its fine to look up the medication if there are several to see what the side effects are). We had no time line established for the depression or cluster headaches. This patient was still having seizures in spite of being on meds. Patient reported a significant weight loss but there was no attempt to quantify it ie how much weight loss over what period of time? Patient reported loss of appetite and change in bowel habits. Did this occur at the same time as the weight loss? When did this all start? If it is recent has anything triggered it? We cant assume it is stress until other possibilities are considered. Regarding the need to urinate little and often when did this start? Was there any pain on micturition? Any difficulty stopping starting? Any haematuria? Was the cyst removed from the testicle benign? When was the surgery? We had no timeline on these systemic events. Were they linked together? Did any of them occur with the back pain? It may be that you did follow up on these issues but you did not tell me so as your examiner I would be left wondering? These would be considered to be omissions in the case history and would lower your grade. Remember to demonstrate to your examiners that you have followed up on all leads in the history. HYPOTHESIS You decided the low back pain was MSK. You considered metastatic spread from the prostate and then discounted it. You considered Lumbar spine, SIJ and Hip as potential structures involved. You hypothesised that there may be a chronic annular strain with justification. Muscular involvement.

Feedback
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It is good to make it explicit to the examiners that you think it is MSK! I was concerned that you considered prostatic metastases as it would seem highly unlikely based on the evidence you presented. You did not discuss differentials for the lower extremity pain i.e. did you think it was neurological in nature or referred or muscular etc.? Try to address each symptom. In view of the fact that this patient had recurring low back pain since 18 the examiners would expect you to consider congenital/ developmental conditions e.g. spina bifida occulta, scoliosis, transitional segments, spondylolisthesis?? The possibility that there may be some inherent structural weakness in the lumbar spine which would predispose him to recurring attacks. You did not address any of the patients systemic symptoms in the hypothesis. Differentials / ideas for the weight loss? Chest tightness? Micturition? Could you do any clinical screening for these or would you advise him to see GP etc.?? Your Proposals for examination CVS exam and BP Lower extremity Neuro including SLRT. Osteopathic exam. Evaluation Your working diagnosis was Right SI strain. PDF by flat AP curves and decreased T spine compliance This was based on the following clinical findings. Neuro testing was negative and CVS exam NAD. BP was 118/80. No sign of anomalies in lumbar spine. Pain on return from active flexion. Decreased ROM from L1-4 and increased ROM at L/S. Decrease ROM in SIJ bilat.

Feedback You did not explain how you had interpreted these findings to reach that conclusion. The SIJs were hypomobile bilaterally but were they symptomatic? Would you expect a male of 38 to have movement in his SIs? This would be open to debate? Was the right one painful to gap or shear? Would an SI strain last for 2o years on and off? Did you do SIFT or STORK tests? Actively stress the SI? Did the patient have any pelvic torsions? Rotations? Leg length discrepancies? Anything that may predispose him to having symptoms on the right?
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You mentioned that the patient had Flat AP curves but did not mention his long spine and morphology and poor muscle tone. Do you think the long history of meds have affected his muscular system? Do you think the hypermobile L/S could be contributing to symptoms? How did this patients spinal mechanics cope with his work commitments? Try to elaborate on you evaluation giving not just the local symptomatic area but also the PDF and MF. Looking over the case now is there any clinical screening you could have done? TTT Plan I did not record your ttt plan and not sure if we discussed it? I think time was up? Cant remember. However in a patient like this the examiners would be interested in whether you would consider any imaging due to the recurring nature? Try to give a short term ttt plan and how you would manage the patient longer term.

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Scenario 4 Case Presentation This was the information that you presented to me: 83 year old female pt. Retired dressmaker. PPW: 1 Left shoulder stiffness /Pain? Feeling of floppiness in arm? Some headaches left side of neck and head. No visual disturbances. Headaches every day -fluctuates since fall. Paracetomol relieves the pain. Onset was 1 year ago after a FOOSH Tripped over box in supermarket. Had Low BP? Went to A and E by ambulance. X-Ray diagnosed Fracture Left shoulder ? Upper humerus? Surgically fixed. Pinned? Plate? Had physio afterwards. Now very restricted in movement. Agg : Active movments of shoulder/ lifting arm > passive movments N/A breathing 2/ Left knee pain. No locking but swelling anterior knee. Onset was after the same fall 1 year ago. 20 years ago patient had blood clot in left leg. Leg has remained swollen throughout since then and feels heavy. Systemically 10St and 52. Decreased weight 1 year ago? When in hospital? Medication: BP, Cholesterol, Omega 3, Omeprazole. No HRT. Feedback This presentation lacked detail. Although it was clear the the main problem was stiffness in the shoulder Im not sure that you enquired about symptoms? You could have explored the C Spine and headaches in more detail and any potential neurological damage in the upper extremity from the fracture. (If you did ask these questions and they were negative you need to show the examiner that you have asked them!) We have very little detail about the knee ie no agg /rel factors and no progression, investigations, previous ttt etc. *Be careful of making statements like There are no visual disturbances so I dont think the headaches are sinister Would a sinister cause of headache always give visual problems? Or could the patient have other symptoms?
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You did explicitly consider bone density issues for this lady and asked about HRT etc and told me at this point you would not HVT this patient! I wondered how relevant this was at this stage as I hope we can reasonably assume that anyone aged 83 might be osteoporotic and we wouldnt HVT them! I was unsure from the presentation whether this lady had high or low BP? She was on medication for BP? but had fallen due to low BP? Confusion here over why she fell? I wondered did you ask her about dizziness, Balance etc? *Think about what you are saying before you say it!! You started talking about an arterial blockage causing swelling in the leg?? What would be more likely to cause poor venous return in the lower extremity? What would your differentials be for oedema in the lower extremities? HYPOTHESES You seemed reluctant to commit yourself to hypotheses at this stage as you were concerned about not knowing where exactly the fracture was and how it had been fixed. Be mindful that an M level student is comfortable with uncertainty! At this stage we are only hypothesising on what might be happening so as long as you can justify your ideas that s fine. When I asked you to consider what may be causing the patients inablity to lift the arm you came up with the following idea

Scar tissue from surgery Capsular restriction/degeneration MM atrophy These all seemed sensible ideas to investigate. This initial discussion is important and you need to structure it as best you can. You needed prompting to consider axillary nerve damage and the potential repercussions of this. You did not provide any hypotheses for the neck and headaches and decided not to focus on the knee in that session. Due to time keeping issues at this stage I agreed it was best to focus on the shoulder. Examination I did not witness the examination due to time constraints with other students.
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Evaluation When I asked you for your evaluation you reported a list of clinical findings as follows: Left leg flexed Protracted Left shoulder Head held flexed Anterior weight bearing Scarring on anterior aspect of left shoulder Barrel chest All active movements shoulder decreased. Flex 90, Abd70, Passive exam was too difficult as pt wouldnt relax? Reflexes P and E T sp rotation was good. No C Sp exam No ARMT around shoulder even though you reported mm wasting in deltoid.

You had not interpreted these findings and did not come to a conclusion. I prompted you to think about : Scapular humeral rhythm. How had the shoulder adapted to the injury? Where was movement coming from? What were your Observations? Was there an inability to lift the arm due to restriction in the joint or muscle weakness? Muscle wasting? Atrophy? Disuse? Neurological damage? You were reluctant to commit yourself to a working diagnosis and when prompted decided on sub acromial impingement syndrome. You had some evidence for this but did not then talk about the bigger picture. We did not really discuss ttt plan and management of the pt. I really lapsed into tutor mode at the end of the session. To summarise: This elderly lady presented with residual stiffness/weakness in her left shoulder following a fracture 1 year ago which was subsequently surgically fixed. The position of the scar suggested the fracture was in the upper shaft of the humerus. She also had stiffness pain and headaches in the left C spine presumably since the jarring of the fall. She had some issues with BP and we are unsure why she fell.
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There were clear indications here for a straightforward T spine C spine and shoulder exam. Active passive and ARMT along with a full neurological assessment. Timekeeping issues meant that it was not possible to investigate the knee problem and the lower extremity oedema. Overall there were a substantial number of omissions snd you needed a lot of prompting to come up with ideas. As an M level student you need to become more self reliant and take charge of the situation. Action Plan More detail in case presentation including negative repsonses that are relevant. Structure your hypothesis before the first discussion. ( Have a look at the handouts Ive attached) Have some order and structure to your examination ( Give patient clear commands when you are examining) Interptret your clinical findings and write down a summary for the patient before the 2nd discussion. (Have a look at the other handout) Have some ideas for ttt and management. Watch timekeeping

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CASE HISTORY TAKING. COMMUNICATION SKILLS. When taking a case history, ask a student peer to give you feedback. Students name Observers name Date

How did the practitioner achieve a therapeutic contract?

Give examples of how the practitioner demonstrated sensitivity

Were the patients fears / concerns / needs acknowledged and reassured? How was this done?

Were red flags sought / explored appropriately? How was this done?

Describe some of the listening skills used:

Were any cues avoided by the patient or practitioner? Give examples.

Describe the practitioners attitude, interested / caring / anxious / bored etc. How was this conveyed?

How was silence used?

How did the practitioner pick up on subtle cues?

How did the practitioner obtain appropriate details in the case? What problems did they encounter?

Was information recorded efficiently? Did this effect the flow of the case history? 37

Did the practitioner make sense of the situation? How was this shown?

How could the communication skills be improved or adapted?

Overall, give 3 areas where the student could improve and how they could achieve this:

Overall, give 3 strengths of the students case history taking skills with examples:

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Considerations to help you focus on clinical reasoning Red Flags II S Greenhalgh & J Selfe Churchill Livingstone 2010, page 17) 1. What are you thinking now? 2. What is your index of suspicion? 3. How many red flags or red herrings are present? 4. What other flags are present? 5. What are your diagnostic alternatives? 6. What is challenging about this case? 7. What assumptions have you made about this case? 8. What is your level of plausibility and certainty? 9. What will you do next with this patient? 10. 11. What have you learnt from this case? Will your future practise change?

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Date

New Patient Clinic Feedback Sheet

Name of lead practitioner Name of Observer Tutor

Please use the spaces below to record your impressions of how your partner performed in the course of this New Patient encounter. Try to make your criticism constructive and an aid to both your learning experiences. th The boxes reflect the 4 Year CCA Assessment Criteria 2011 but are for guidance only make any comment you feel appropriate. At the end of the session try to spend a few minutes in constructive feedback.

Case history: Speed Problem B4 XS lifestyle Qs Open questions Clinical curiosity Clinical Observation and Evaluation Looks beyond TCS Checks bony levels Checks sitting posture Structured Segmental analysis Time keeping Clinical Reasoning and Decision Making Multifactorial Specific terminology Considers validity of tests More than tender area Osteopathic Evaluation and Patient Management Interpret findings Identify underlying processes Bio-mechanical factors Psycho-social factors Applied Osteopathic Techniques Patient comfort Enough time for this? Consent gained? Effective Reasoned Own posture Reflective Professionalism and Communication Skills Explanations to patient Attire Terminology Consent Confidence Equipment

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