27.9.2012 Tutorial on active examination of the knee joint
At the team point we were discussing with colleagues the Manus talk from the night before and out tutor Mrs. P. was listening with interest. She found the ideas we were discussing very interesting and as usual, she challenged us and a small group of us, made of perhaps 5 people, she asked to sit down together and outline how would we examine the knee with the functional approach.
We split the functional examination into observation of the patient's gait, squatting and split lunges. We discussed the importance of the foot and hip mechanics associated with knee problems. We came to the conclusion that when assessing knee, we need to take in account the foot mechanics - i.e. pronation/supination, amount of dorsiflexion available in the foot, stability and balance/proprioception ability, any previous foot and ankle injuries and pes planus/varus as main variables. With the hip there is important the strength and balance of the gluteal musces, ample hip extention available, good and balanced ROM of int. and ext. rotation, adductors length, strenght and function. These will influence the tone of muscles crossing the knee joint (quadriceps, hamstrings, gastrocs, adductors) and their influence on the knee function, stability and efficiency. We came to the conclusion that typical orthopeadic tests for the knee joint will tell us more about the structures damaged but not about the reason why this happened to occur.
I found this tutorial very helpful as immediately afterwards I had a new patient that presented with a knee problem. I did all the functional examinations we discussed previously. I learn best by doing things and I found it really convenient to have an opportunity to examine the knee joint in the functional way.
We split the functional examination into observation of the patient's gait, squatting and split lunges. We discussed the importance of the foot and hip mechanics associated with knee problems. We came to the conclusion that when assessing knee, we need to take in account the foot mechanics - i.e. pronation/supination, amount of dorsiflexion available in the foot, stability and balance/proprioception ability, any previous foot and ankle injuries and pes planus/varus as main variables. With the hip there is important the strength and balance of the gluteal musces, ample hip extention available, good and balanced ROM of int. and ext. rotation, adductors length, strenght and function. These will influence the tone of muscles crossing the knee joint (quadriceps, hamstrings, gastrocs, adductors) and their influence on the knee function, stability and efficiency. We came to the conclusion that typical orthopeadic tests for the knee joint will tell us more about the structures damaged but not about the reason why this happened to occur.
I found this tutorial very helpful as immediately afterwards I had a new patient that presented with a knee problem. I did all the functional examinations we discussed previously. I learn best by doing things and I found it really convenient to have an opportunity to examine the knee joint in the functional way.
18.10.2012 Palpation of the forearm and pediatrics osteopathy
We were 4 students today observing at the 1st place. During the tutorial we palpated each others forearm and felt for a different tissues and also fluid dynamics of the forearm. The tutor told us about her experience of a previously fractured forearm that after healing was still hurting. On palpation she sensed the forearm felt like a fork - trauma was still stored in the tissue memory.
It was interesting to palpate and to be palpated and give a feedback about what I felt was being done to me and if it matched with the intention of the practitioner.
It was interesting to palpate and to be palpated and give a feedback about what I felt was being done to me and if it matched with the intention of the practitioner.
22.10.2012 Tutorial on the patient that wanted to switch the osteopath
Today our clinic tutor told us about her own experience. A patient rang her and wanted to be seen by her after being treated three times in one week by a different osteopath. The patient was happy with the treatment but for an insurance purposes wanted to switch to our clinic tutor. We discussed different aspects of the problem. One was how soon after a treatment somebody else gave to the patient would you be happy to treat them. Also we discussed the reasons why would a patient get three treatment in one week. There are legitimate reasons for treatment but however we considered also a possibility of previous osteopath being unethical and trying to squeeze out as much money from the patient as possible before they switched to the different practitioner. It is important to make sure that patients do not receive any different treatments while we treat them as legally this would be difficult to find out who cause them damage if there was any to occur. Thus as a conclusion our tutors agreed that leaving about a week after somebody else treatment would be reasonable as the reaction to the treatment has enough time to take place. Always ask the patient what other treatments do they receive and if needed ask them to discontinue them while receiving ostepathic treatment or refuse to treat them any further.
30.10.2012 Tutorial about the patient with the AAA
Our clinic tutor challenged us with a case of a male that presented to her with thoracic and shoulder pain. He has been previously diagnosed with AAA that has been stable, recently monitored each 3 months. It was important to see if the pain he experienced was from the AAA or was of a mechanical nature. The discussion was mainly if we would decide to carry out a CVS exam if we encountered this patient. Many said that they would as they wanted to have a bench mark readings for future reference and something to cover their backs. Other group of students argued that they would not take CVS exam as the patient is monitored and medicated and as we take case history and see the nature of the pain and relieving and aggravating factors, if it is clearly musculoskeletal and also proven by examination to be so, there is no need to do CVS exam. This exercise didn't give us an answer what is right and what is wrong decision but it was for us to realise that we need to back up our decisions by reasoning once we are in practice and during the CCAs.
6.11.2012 Tutorial on the patient with no symptoms
DC today explored the possibilities that we could encounter a patient without symptoms during out CCAs. He reckons it is a blessing from the sky as we can do anything. Every person has a certain lifestyle we can advise on and which affects their bodies so this can be explored. it is important to look at the diet, age, gender of the person (do they need CVS and respiratory exam perhaps?). DC also told us that every patient comes through the door for a reason. It might be a worry they might have a problem somebody related to them has, or just perhaps just looking for an MOT and advice how to keep functioning in the best way possible. Our aim as osteopaths is to promote the health and maintain the function. Therefore we can use the patient like that for our advantage and not fear this could lead to fail in the exam.
20.11.2012 Tutorial on spinal cord facilitation vs somatic dysfunction
Mr MS today finally explained the facilitation of spinal cord and somatic dysfunction. there is never a somatic dysfunction without facilitation. the facilitation is a result of a repeated insult of a tissue in the body that makes the corresponding spinal cord segment hypersensitive and this causes the surrounding tissue of the corresponding spinal joint to change causing somatic dysfunction. this can be identified by using TART acronym: tenderness, asymmetry, restricted movement and tissue texture change.
9.1.2013 Personal one to one tutorial with the clinic tutor Mr T.
It has been second time in the row that my new patient would not turn up. I was the only one that left in the team point unassigned to any patient treatment or observation. Mr T, my wednesday clinic tutor decided to challenge me with a case presentation in order to help me thinking in a way so when a real patient presents with a problem, I can very quickly sieve through the possibilities they may present with. He challenged me with the case of bilateral medial leg pain that was of mechanical type. He wanted me to think in the order;
1. local problem (what tissues are in the leg to cause pain - vessels, bones, muscles, nerves, some ligaments and tendons)
2. pain referred from somewhere else - lower back, ankles, feet or knees.
3. neurogenic pain (find out if the pt has any lower back problem)
4. systemic (local problem investigation would help it but for example if it is claudication pain, then we have to think of the arteries further away from the legs)
Always ask the patient if they have a similar problem/pain in any other parts/joints of the body. This is just to exclude systemic disorders such as RA for example.
This session with Mr T. was very helpful actually and I am looking forward to encounter a next new patient and see how can i implement his advice in practice.
1. local problem (what tissues are in the leg to cause pain - vessels, bones, muscles, nerves, some ligaments and tendons)
2. pain referred from somewhere else - lower back, ankles, feet or knees.
3. neurogenic pain (find out if the pt has any lower back problem)
4. systemic (local problem investigation would help it but for example if it is claudication pain, then we have to think of the arteries further away from the legs)
Always ask the patient if they have a similar problem/pain in any other parts/joints of the body. This is just to exclude systemic disorders such as RA for example.
This session with Mr T. was very helpful actually and I am looking forward to encounter a next new patient and see how can i implement his advice in practice.
22.1.2013 Tuesday tutorials - patient case scenarios in depth analysis
From today onwards on tuesdays we will be analysing the case scenarios one of us, students will present and the rest of the team will in depth investigate the reasons for some certain symptom presentation. It was my turn today to present the case study and assign the tasks to my colleagues:
Case study
Patient: Female, 55 yoa, widow of 9 years.
Work: PA (last 30 years)
Hobbies: wine tasting, visiting galleries, painting
Height and weight: 5’6’’ and 10.5st. Recently lost 0.5st for NAR.
PPW: Right leg weakness with limping while walking. Bilateral numbness in buttocks and numbness in R>L thighs. Sometimes night or day pain in right leg of shooting or burning character (comes and goes). No LBP.
Onset: over last 2-3 months for NAR
Progression: worsening
Hxx: aged 34 had prolapsed disc at L4/5 with LBP and sciatica into the R leg. Had osteo ttt that helped. Since then no problem with LB.
Current general health: recently feels very weak generally and fatigued all the time.
Sleep: wakes up due to the pain in the leg, had similar pain few weeks ago in the UExs too. Difficult to sleep, watches telly or has a glass of wine to get “tired”. Gets 4-5 hrs of sleep max.
Prev. serious diseases: Jaundice as child, pneumonia teenager.
Surgeries: Hysterectomy 4 years ago
RTA and fractures: 2 years ago fell on the stairs in the tube when returning from wine tasting. Hit her head and was unconscious, in hospital ttt for 2 days, than went home with multiple bruises. Had some scans, all was ok but concussed.
Allergies: tetracycline
GIT: decreased appetite. Recently very often constipated.
CVS: BP always low. R foot feels cold all the time (since about 3 months ago)
Neurological: Vision has changed recently, feels like she can not see the mirror (on the R side) when driving as she used to, has to turn her head more. Increased frontal headaches but thinks it is because drinks too much wine in the night. Has also developed slight tremor in her hands and feels unsteady when walking so drives everywhere.
Respiratory: Feels difficult breathing probably due to the general fatigue. Used to smoke until the 9 years ago when her husband died of lung cancer.
Tasks
What other questions would you ask your patient, and why, to investigate the below listed symptoms/problems? List all possible health issues that could cause particular symptoms:
1. Tiredness and fatigue, difficulty to sleep – Joel
2. Decreased appetite and constipation – Maddie
3. Hysterectomy – Liz
4. Difficulty breathing – Laura
5. Vision changes – Sam
6. Lower back pain – Radi
7. Cold extremities and low blood pressure – Steven
8. Tremor – Christina
9. Frontal headaches – Lucia
Case study
Patient: Female, 55 yoa, widow of 9 years.
Work: PA (last 30 years)
Hobbies: wine tasting, visiting galleries, painting
Height and weight: 5’6’’ and 10.5st. Recently lost 0.5st for NAR.
PPW: Right leg weakness with limping while walking. Bilateral numbness in buttocks and numbness in R>L thighs. Sometimes night or day pain in right leg of shooting or burning character (comes and goes). No LBP.
Onset: over last 2-3 months for NAR
Progression: worsening
Hxx: aged 34 had prolapsed disc at L4/5 with LBP and sciatica into the R leg. Had osteo ttt that helped. Since then no problem with LB.
Current general health: recently feels very weak generally and fatigued all the time.
Sleep: wakes up due to the pain in the leg, had similar pain few weeks ago in the UExs too. Difficult to sleep, watches telly or has a glass of wine to get “tired”. Gets 4-5 hrs of sleep max.
Prev. serious diseases: Jaundice as child, pneumonia teenager.
Surgeries: Hysterectomy 4 years ago
RTA and fractures: 2 years ago fell on the stairs in the tube when returning from wine tasting. Hit her head and was unconscious, in hospital ttt for 2 days, than went home with multiple bruises. Had some scans, all was ok but concussed.
Allergies: tetracycline
GIT: decreased appetite. Recently very often constipated.
CVS: BP always low. R foot feels cold all the time (since about 3 months ago)
Neurological: Vision has changed recently, feels like she can not see the mirror (on the R side) when driving as she used to, has to turn her head more. Increased frontal headaches but thinks it is because drinks too much wine in the night. Has also developed slight tremor in her hands and feels unsteady when walking so drives everywhere.
Respiratory: Feels difficult breathing probably due to the general fatigue. Used to smoke until the 9 years ago when her husband died of lung cancer.
Tasks
What other questions would you ask your patient, and why, to investigate the below listed symptoms/problems? List all possible health issues that could cause particular symptoms:
1. Tiredness and fatigue, difficulty to sleep – Joel
2. Decreased appetite and constipation – Maddie
3. Hysterectomy – Liz
4. Difficulty breathing – Laura
5. Vision changes – Sam
6. Lower back pain – Radi
7. Cold extremities and low blood pressure – Steven
8. Tremor – Christina
9. Frontal headaches – Lucia
5.2.2013 - Patient case scenario from Maddie G.
My colleague presented another patient today and I was instructed to investigate the prolactinoma. These are my findings:
Prolactinoma
What is it?
A prolactinoma is a benign tumour/adenoma of the pituitary gland, which produces an excessive amount of the hormone prolactin. Prolactin is a natural hormone, which supports a woman's normal lactation. Prolactinomas are the most common type of pituitary tumour.
Symptoms of prolactinoma are caused by pressure of the tumour on surrounding tissues (headaches or visual disturbances due to pressure on the optic chiasm) or by excessive release of prolactin from the tumour into the blood causing hyperprolactinemia.
Symptoms
In women, high blood levels of prolactin usually interfere with ovulation, causing infertility and changing menstruation. In some women, periods may disappear altogether whereas in others, periods become irregular, or menstrual flow may change noticeably. Women who are not pregnant or nursing may begin producing breast milk. Some women may experience a loss of libido. Intercourse may become painful because of vaginal dryness.
In men, the most common symptom of prolactinoma is impotence. Men have no reliable indicator such as menstruation to signal a problem. Thus, many men delay going to the doctor until they have headaches or vision problems, caused by the enlarged pituitary pressing against the nearby nerves from the eyes. Men may not recognize a gradual loss of sexual function or libido. In fact, only after treatment do some men realize they had a problem with sexual function. As a result of later presentation, men on average, have larger prolactinomas at their presentation then women.
Treatment
Prolactinomas are usually initially treated with medications (bromocriptine or cabergoline – they act in a similar way as dopamine).
Surgery is considered if the medications cannot be tolerated, or if they are not effective.
The medical treatment may be only partially successful. In such cases, the medications may be combined with surgery or radiation therapy.
Prolactinoma
What is it?
A prolactinoma is a benign tumour/adenoma of the pituitary gland, which produces an excessive amount of the hormone prolactin. Prolactin is a natural hormone, which supports a woman's normal lactation. Prolactinomas are the most common type of pituitary tumour.
Symptoms of prolactinoma are caused by pressure of the tumour on surrounding tissues (headaches or visual disturbances due to pressure on the optic chiasm) or by excessive release of prolactin from the tumour into the blood causing hyperprolactinemia.
Symptoms
In women, high blood levels of prolactin usually interfere with ovulation, causing infertility and changing menstruation. In some women, periods may disappear altogether whereas in others, periods become irregular, or menstrual flow may change noticeably. Women who are not pregnant or nursing may begin producing breast milk. Some women may experience a loss of libido. Intercourse may become painful because of vaginal dryness.
In men, the most common symptom of prolactinoma is impotence. Men have no reliable indicator such as menstruation to signal a problem. Thus, many men delay going to the doctor until they have headaches or vision problems, caused by the enlarged pituitary pressing against the nearby nerves from the eyes. Men may not recognize a gradual loss of sexual function or libido. In fact, only after treatment do some men realize they had a problem with sexual function. As a result of later presentation, men on average, have larger prolactinomas at their presentation then women.
Treatment
Prolactinomas are usually initially treated with medications (bromocriptine or cabergoline – they act in a similar way as dopamine).
Surgery is considered if the medications cannot be tolerated, or if they are not effective.
The medical treatment may be only partially successful. In such cases, the medications may be combined with surgery or radiation therapy.
March 2013 - Tutorials with aim to provide differential diagnosis and practice DCP
The majority of the tutorials before the CCA no1 were aimed towards getting the team working together and brainstorm while thinking of possible differential diagnosis. the cases presented had always a component of systemic issues so on the end of each tutorial a chosen student would perform in front of the group a specific DCP examination with the group then giving a feedback on how it went and how they would do it differently and why.
Many of the tutorials were also aimed towards answering the concerns and questions the students had before the CCAs that was very helpful and reassuring.
Many of the tutorials were also aimed towards answering the concerns and questions the students had before the CCAs that was very helpful and reassuring.
Easter holiday clinic tutorials
There were not many, mainly run by trevor Jefferies as an neurology catch up. it seems that we are supposed to learn basic neurological stuff we should have known in first year! I particularly did not have much use of these tutorials as they were run in the afternoon, and as i was busy and almost every day booked back to back, i rarely made it to tutorial, just trying to catch up with notes taking and stuff. Once i made it and i realised that it was very well put together presentation of the things i had to study by myself in order to comprehend the clinical relevance of the neurology.
19.4.2013 - neuro exam with Kylie from Australia
In East Street Kylie showed us today how they carry out the neurological examination in Australia. The CNs exam is kind of same however the majority of the general neuro exam is done with the patient seated. Reflexes - she took only biceps and triceps reflex. On the lower extremity with the legs hanging, the knee response is obvious, with the plantar jerk she held the foot in her hand while she tapped the stretched gastrosoleal tendon. she could feel the response in her hand as the foot gently plantar flexed. After she checked for babinsky reflex. She then tested for cerebellar dysfuncton - nose to finger test and on the feet heel to shin test, dysdiadochokineasia (patient uses both hands at the same time and alternates the tapping on the thighs), rebounce phenomenon, pendular reflex (is visible on knee reflex). For power she tested for 5 seconds each muscle group. the patient is encouraged to use all his/her power to show how strong they are. She uses grading system for power and for reflexes from 1 to 5. she then tested for joint position sense. she held my hand and with the other she held the finger on the side of the nail and she would gently wobble the distal phalange before she would go up or down. she also introduced this movements to the patient first. Pt has eyes closed. Pin prick - patient lying down, she first tests on the sternum for sharp and blunt feeling. she then goes down the arm and legs to see if the patient can distinguish between this feelings. then she compares left and right side for any differences. Also she maps out any area of diminished sensation for future reference and benchmarking. She uses large for for vibration. she tests this on the sternum and then on the end of the fingers. We had debate whether it is needed to do soft touch test. we did not come to conclusion but Trevor Jeffries told us not to, where else she does it.
Kylie also could not understand why we are encouraged to rush through with our DCP exams when they are so important to identify any defficiencies in the patients. She would take easily up to 20 minutes to test thoroughly for any neurological deficits as patients wellbeing is most important.
Kylie also could not understand why we are encouraged to rush through with our DCP exams when they are so important to identify any defficiencies in the patients. She would take easily up to 20 minutes to test thoroughly for any neurological deficits as patients wellbeing is most important.
25.4.2013 - CCA pretending with Clarissa
Clarissa told us to prepare for this week to present and have differencial diagnoses for Radi's patient that presented with the hip pain and a complex systemic history. Then in the morning she split us up into 4 groups and we were pretending to be in CCAs, one group asking particular students detailed questions relevant to the presentation of the patient. As we had 20 mins for preparation and only 20 mins remained for the actual role play, we did not get too far but it was a good idea for using this system in study group preparation.
30.4.2013 - Gait analysis with mr Stewart
This was not new concept to me entirely but mr stewart pointed as certain hip and feet issues that were very relevant in understanding how the gait occurs and how compensations come into place once something does not work as it is supposed to. I think i will be much happier now to appreciate the finding in the feet , knees and hips to understand the links between them and possible issues in gait and how these can affect the lumbar spine of SIJ function and injuries.
for next week we will be talking about dizziness and scoliosis.
for next week we will be talking about dizziness and scoliosis.