Download VP Storyboard Branching Example - MedNet

Note: This is a real case created in Visual Understanding Environment (VUE); free software download from: http://vue.tufts.edu/
Zoom: Magnify the PDF to 600% to read examples of the written content for each branching node.
Neveah is a 7-year-old girl who has been referred to the paediatric rheumatology clinic at the Tertiary Care Hospital. She attends the clinic with her grandparents who are her caregivers
while her mother is away in Prince George at The University of Northern British Columbia studying to be a teacher. Her father is not involved in her care.
Neveah is a member of the Nisga'a First Nation and lives on reserve in New Aiyansh with her grandparents and two siblings, a brother who is four years old
and a sister who is two years old. Nikita is in grade 2 and has done well at school.
In the past three months, she has missed 15 days of school and has been late for most other days because of joint pain.
Within this case, you are acting inthe role of the physical therapist as part of the paediatric rheumatology specialist team.
tasminhallworth.jpg
What do you think is the role of the physical therapist in the management of juvenile idiopathic arthritis?
List four ways in which a physical therapist may have a role in a case such as this. You have not examined Nikita
yet, and so you are not asked to identify specific treatment goals at this time - just answer in general.
Type your response in your electronic notes.
The role of the physical therapist in this case is to assist in the management of Neveah's chronic pain and joint disease through
education, exercise, physical modalities and adaptations. The overall goals of rehabilitation for patients with JIA include
pain relief, increase range of motion (ROM), increase muscle strength/length and endurance,
prevention and correction of deformities, correction of faulty postural or functional movement patterns, improve balance and balance reactions, improve bone density, and provide various counseling,
educational and family and community support services.
Other important roles include liaison with school administration, and teachers (both general and physical education) to facilitate Nikita's attendance at school. This list is not meant to be a list of specific treatment goals
for Neveah today, rather it is intended to get you thinking about the general role of PT in the management of JIA.
Also to work with members of the specialty team in caring for the patient.
What are the signs and symptoms of JIA? Write your response in the notes, then continue with the case.
Signs & Symptoms of JIA
pain
swollen joints
restricted function
a.m. stiffness
fatigue
restricted ROM
restricted muscle strength and length
abnormal gait
growth abnormalities
asymmetric posture and movement patterns
some of the seven sub-types of JIA exhibit
fever and rash
Nikita is sitting in the waiting room of your clinic. She is accompanied by an elderly female - presumably her grandmother. Nikita is small for her age, and looks uncomfortable.
You invite the pair into the examination room. Nikita is very shy, you have difficulty engaging her, but she seems to be cooperative. She prefers to sit on her grandmother's lap.
Her grandmother answers questions for her. You want to find out more history. You have been taught that generally speaking, your client should answer your questions.
Do you choose to persist in trying to get Nikita to answer your questions, or do you allow her grandmother to answer your questions for Nikita?
a. Persist in trying to get Nikita to answer.
b. Allow her grandmother to answer.
a. persist in trying to get Nikita to answer
This is not the best approach in this case. Remember the Neveah is only seven, and will probably be shy and afraid.
She will need more time to get comfortable in the strange setting of the clinic.
Most often parents or guardians will provide the history and answer questions for young children.
You may want to engage her in play to facilitate the assessment.
b. allow her grandmother to answer
This is the best option in this case. Remember the Neveah is only seven, and will probably be shy and afraid.
She will need more time to get comfortable in the strange setting of the clinic.
Most often parents or guardians will provide the history and answer questions for young children.
You may want to engage her in play to facilitate the assessment.
Culturally, the young are expected to defer to their elders...
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Click here to find out about the history of the presenting illness.
What would you like to do first?
a. examine the patient?
b. take some further history?
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a. examine the patient.
b. Take some further history
Correct!
Click here to learn more of the history of this presentation.
At this point you don't have enough background information to
begin the physical examination. You should ask some questions to gain a clearer picture
of the problems before proceeding with the physical examination.
Nikita complained of knee pain following T-ball game eight months ago, in which she has tripped and fell.
When the pain persisted, her grandmother took her to the local family doctor who found the left knee warm and slightly swollen.
A diagnosis of a sport injury was made. It was recommended that Nikita should rest the knee (avoid vigorous activity), ice the knee regularly, and take acetaminophen as needed for pain.
At eight months' duration, is this considered to be acute inflammation or chronic inflammation
a. acute inflammation
b. chronic inflammation
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a. acute inflammation
Think some more about the nature of inflammation. What do you remember as the time-frame for healing
to occur? Chronic inflammation is inflammation that has (generally) not resolved after three months and
is characterised by a persistent shift in the type of inflammartory
cells present in the inflammed tissue.
Acute inflammation is considered to be (generally) resolved within three months.
There are more specific indicators based on the cell type predominantly found in the inflammation, but
this time frame is a general guide for most soft tissue inflammation.
However, in the case of arthropathy, inflammation lasting for six weeks is considered to be chronic.
The definition of JIA includes "inflammation in a joint that lasts longer than 6 weeks, in a child less than 16 years old."
b. chronic inflammation
Correct choice!
Chronic inflammation is inflammation that has (generally) not resolved after three months and
is characterised by a persistent shift in the type of inflammartory
cells present in the inflammed tissue.
Acute inflammation is considered to be (generally) resolved within three months.
There are more specific indicators based on the cell type predominantly found in the inflammation, but
this time frame is a general guide for most soft tissue inflammation. However, in the case of arthropathy,
inflammation lasting for six weeks is considered to be chronic.
The definition of JIA includes "inflammation in a joint that lasts longer than 6 weeks, in a child less than 16 years old."
Do you want some further information about inflammation? Or to continue with the case?
Click "Next" to continue.
List the five clinical signs of inflammation in the box below, then click "Next" to continue the case.
Swelling-knee.jpg
The five "cardinal" signs of inflammation are:
Pain
Heat
Redness
Swelling
Loss of function
Click "Next" to continue.
Three months have passed since the initial injury.
Nikita's knee continued to be sore and swollen.
Her family physician referred her to the orthopaedic surgeon
who visited the area every six months.
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Do you think that a joint tap (for synovial fluid testing) should be performed?
This is not a PT decision but let's discuss for your information.
No, no joint tap necessary
Yes, perform a joint tap
No joint tap necessary. Correct!
A joint tap is invasive and carries with it a risk of infection. It would not be done to confirm a diagnosis
of arthritis.
There is no lab test that can be used to give a diagnosis of JIA, which is made by clinical diagnosis.
However, in the past patients with JIA received synovial fluid analysis, which would typically show the following...
JIA synovial fluid analysis (on S drive)
joint aspiration.JPG
Just as an aside, did you notice fromthe lab report that the fluid in the analysis is clear? If you see clear synovial fluid in a joint aspiration,
what would be your first thought?
a. a non-infective process is occurring in the knee
b. an infective process is occurring in the knee
c. a traumatic process has occurred in the knee
d. cannot decide on the nature of the process without further information
a. a non-infective process is occuring in the knee
Although you would need to have the results of the lab test to be sure, at this stage you recognize that there is probably no overt infection in the knee that is, that this is not a septic joint. Neither has there been significant trauma - there is no hemarthrosis.
Further, an infective process in the knee would have presented with more acute
problems within days or weeks. The patient would have looked more ill, and likely been unable to walk.
Click here to see the results of Nikita's synovial fluid analysis.
Click "Next" to continue.
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Click here to see images of different synovial aspirates
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b. an infective process is occurring in the knee
Although you would need to have the results of the lab test to be sure, based on the synovial aspirate there is probably
no overt infection in the knee - that is, that this is not a septic joint. If the joint were septic (infective process)
you would expect to see turbid, non-viscous synovial fluid aspirate.
Click here for further information about septic arthritis. Click "Back" to continue with the case.
c. a traumatic process
Here you might wonder if there has been knee trauma, in which case, there might be blood
in the synovial fluid. Because the synovial fluid is clear, you can be sure that this is not
frank hemarthrosis, that is, a significant trauma is unlikely in this case.
Netter - synovial fluid.jpg
d. cannot decide on infective or non-infective without further information
Although you would need to have the results of the lab test to be sure, based on the synovial aspirate there is probably
no overt infection or trauma to the knee - that is, that this is not a septic or haemorrhagic joint. If the joint were septic (infective process)
you would expect to see turbid, non-viscous synovial fluid aspirate. A haemorrhagic joint would have blood in the synovial fluid.
Click here for further information about septic arthritis. Click "Back" to continue with the case.
Netter - synovial fluid.jpg
Netter - synovial fluid.jpg
RA_gout_synovial.jpg
septic_synovial.jpg
What joint structures are affected in JIA?
Write your answer before continuing with the case.
Joint structures affected by JIA include:
joint synovium
tendon sheath synovium
entheses
bone (premature fusion, erosions, bony overgrowth)
Nikita's knee is still hurting her. She was starting to find it difficult to walk to and from school.
She also told her grandmother that her mouth hurt when she tried to eat apples, and that her hands got sore when she
was colouring pictures at school. At this point, the doctor referred Nikita to the paediatric rheumatology program at the
Tertiary Care Hospital. Arrangements were made for Nikita and her grandparents to travel to Vancouver.
Nikita and her grandmother have finished telling the story of how Nikita came to the rheumatology clinic.
You look in the chart to read the rheumatologist's report.
Click here to see the rheumatologist's report. xxxxxxxxxxxxxxxxxxxxxx
As part of the inital assessment, Neveah was referred to an ophthalmologist
Why?
Asymptomatic uveitis can occur in children with JIA.
In certain subtypes of JIA, as many as 50% of children will get uveitis.
Link to article doi:10.1542/peds.2006-0421
474pxSlit_lamp_Eye_examination_by_Ophthalmologist...
Blood test results show the following:
Negative for rheumatoid factor
ESR (erythrocyte sedimentation rate) is 78
Anti-nuclear antibody test - positive
doi: 10.1016/j.rdc.2007.07.006
doi:10.1016/j.autrev.2005.09.011
Medications
Naproxen: 250 mg daily orally in divided dosage
Methotrexate: 10 mg weekly orally
Folic acid: 1 mg daily orally
Prednisone: 10 mg daily orally, to be tapered slowly over the next eight weeks
Steroid eye-drops: one drop in each eye, q.i.d (click for medical abbreviations)
What do you want to do now?
a. take some more history
b. proceed with the physical examination
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b. proceed with the physical examination
Correct!
Which test / evaluation would you like to begin with?
a. examination of joint range of motion (ROM)
b. assessment of balance
c. assessment of muscle strength
d. specific examination of the left knee
e. active joint count (assess every joint)
a. take some more history
You probably have enough backgound information now
to begin the physical examination
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a. examination of joint ROM
A good choice, but in this case, you need to perform a "joint count" first.
Click here to learn more about performing a joint count.
b. assessment of balance
Not the best choice at this time. You might want to start with something that is
more fundamental to balance. In this case you need to perform a "joint count" first.
Click here to learn more about performing a joint count.
c. assessment of muscle strength
A good choice, however in this case you need to perform a "joint count" first.
Click here to learn more about performing a joint count.. Nikita has inflammed joints which would
be uncomfortable if muscle testing were to be performed, however, you will eventually want some indication of muscle strength.
d. Specific examination of the knee
Not the best choice in this case. In patients wih systemic
disease, such as juvenile idiopathic arthritis, it is important to have a sound base-line of measures
such as joint ROM to ensure that you know the starting point for monitoring
disease progression.
e. Perform the "active joint count"
Correct response! In a patient with inflammatory arthritis, it is important to begin
the examination with an assessment of every joint - the "joint count". Generally the rheumatologist will have carried out this examination.
You do not need to redo the joint count if one has recently been performed.
Begin by examining the joint for swelling and warmth. If no swelling is observed, then palpate for joint line tenderness.If no joint line tenderness is elicited,
look for limitations in ROM. Then test by stressing the joint at end of range (overpressure pain) .
There is no need to test overpressure if the joint is swollen/tender.
If all four tests are negative, the joint is considered to be not an active joint.
Click here to learn more about performing a joint count.
Clare's active joint count
skeleton
Proceed to the second JIA virtual case Objective examination and treatment planning.
First, let's review the learning objectives from this part of the case
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With thanks to:
S. Jayne Garland, PhD, PT - Professor and Head, Department of Physical Therapy, Faculty of Medicine, University of British Columbia
Brenda Loveridge, PhD, PT – Associate Dean Health Professions, University of British Columbia
Joseph Anthony, PhD, PT – Internationally Educated Physiotherapists (IEP) Virtual Patient Project, Clinical Associate Professor, Department of Physical Therapy, Faculty of Medicine, University of British Columbia
Clare Newlands, BEng – IEP Virtual Patient Project, Instructional Designer
Darlene Redenbach, PhD PT - IEP Pedagogical Review, Senior Instructor, Department of Physical Therapy, Faculty of Medicine, University of British Columbia
Gillian Parker, PT - IEP Pedagogical Review. Administrator, Internationally Educated Physiotherapists Program
Anne Rankin, MScPT - IEP Pedagogical Review, Clinical Assistant Professor, Department of Physical Therapy, Faculty of Medicine, University of British Columbia
Zachary Rothman – Filming / Editing
Medical Review:
Dr Lori Tucker, Division of Paediatric Rheumatology, Dept of Paediatrics, University of British Columbia & BC Children's Hospital
Dr Mercedes Chan, Division of Paediatric Rheumatology, Dept of Paediatrics, University of British Columbia & BC Children's Hospital
Dr Michael Hunt, Michael Hunt, PhD, PT. Assistant Professor, Department of Physical Therapy, Faculty of Medicine, University of British Columbia
Department of Physical Therapy, The University of British Columbia, Vancouver, Canada
for his assistance with the gait analysis section.