This document describes a virtual clinical examination case involving an interactive paper patient with congenital knee deformity (CKD). The examinee is presented with phases of the case and asked questions to evaluate their clinical reasoning. Phase 1 involves collecting a history and performing a focused exam. Phase 2 involves diagnosing CKD and discussing investigations. Phase 3 involves interpreting x-rays and determining next steps. Phase 4 involves formulating a management plan including non-operative and surgical options. The virtual case aims to simulate a real clinical encounter using an inexpensive interactive paper format.

1. VIRTUAL CLINICAL
EXAMINATION
“INTERACTIVE PAPER
PATIENT”
[VERSION-2]
Prof. Anisuddin Bhatti
Dr. Ziuaddin University Hospital
Clifton, Karachi.
dranisbhatti@gmail.com

2. Virtual Clinical Examination
• Virtual Clinical Examination (VCE) employs
Virtual Patients (VPs) in clinical examinations
instead of real patients.
• VPs are developed as computer-based programs
that simulate real-life clinical scenarios. (Cook et al, 2010).
• Clinical examination, however, requires a linear
dialogue between examiner and examinee, for
which VPs need to be adapted accordingly
Harless et al 1971 & Cook et al, 2010.

3. Virtual Clinical Examination
• Virtual Clinical Examination provides an
Interactive role to the examinee, as opposed
to passively watching videos/ visuals and
answering written or oral questions.
• Examinee is required to interact with the
examiner by posing and answering questions
regarding evolving condition of the patient
presented.
(Huang G, Reynolds R, Candler C).

4. Interactive Paper Patients(IPPs)
• This led to development of an
inexpensive tool: IPPs, which has been
used extensively for many years in
cognitive assessment as:
• Modified Essay Questions (MEQs)
• Patient Management Problems (PMPs)

5. Process
• IPPs reveal patient condition and
workup phase-wise.
• Examiner poses questions to the
examinee after description of
each phase.
• Student can ask questions about
patient condition, investigation
or response to therapy.
• Examiner responds verbally or
furnishes results.
• Answers are scored phase-wise
on a key.

6. CASE
EXAMPLE
Short case: CKD

8. Phase1-3Marks: 1a: History 1 marks
• 2 wks old baby
Born NVD
• Now, the student should
collect some more
information on history
and perform focused
examination, you may
ask:
1. What additional points
you would like to gather
on history?

9. What additional Questions U like to
ask?
1. Family history
2. Drug history
3. Oligohydromnios

10. Phase 1b
Clinical
Examination
1 marks
• What focused
clinical
examination
is needed
and what
are the
expected
findings?
• Screening
Exm: Quik
Survey
• General Exm:
Quik Detail
• Systemic Exm:
quik Other
than MSK
• Detailed MSK
Examination

11. Detailed MSK
Examination
2 marks
LOOK, FEEL & MOVE
1. Feet ?
 CAVE
1. Knee ?
 Architecture, Deformity, Dimple
 ROM
1. Hips?
 Abduction
 Gallazia
 Ortloni Barlows
• Spine?
 Dimple
 Bifida Occulta
• Exclude AGMC

14. Associated Deformities with CKD
Associated conditions
• developmental dysplasia of the hip
• clubfoot
• metatarsus adductus

15. Phase-2. 1 marks
After Candidate has furnished his findings on
history and examination, Examiner may ask:
1. What is the likely diagnosis and why?
2. How to define grading of the deformity?
3. What investigations you would like to
order and why?

16. Examination Findings
• Limited B/L knee flexion
• B/L knee recurvatum +ve
• MCL lax
• Hip ROM normal

17. Tarek CDK Grading System

18. Phase-3: 2 marks
If the candidate orders some
investigations such as X-Ray show
him the X-Ray (and not the report)
and ask him:
1. What do you find on X-
Ray?
2. How will you proceed
further?
If the candidate reads X-Ray
correctly, draw referral lines and
request additional imaging show him
and ask why
CT / MRI

19. At 5
month
age

20. Phase 4.
Management
plan
3 marks.
Each section
carries 1mark
Now it may be
revealed that
examiner has
declared him fit, he
shall ask treatment
strategies.
Q. Non-operatieve
or
Operative
Justify
1. What specific
Non operative
Rx & How.
1. If failed to
achieve
satisfactory
results how to
proceed?
2. What specific
surgical
procedure you
would
undertake and
why?

21. Chun Chien Cheng &
Jih Yang Ko

22. Surgical
Procedure
In case of failure to achieve satisfactory result
or delayed presentation
Q. What specific surgical
procedure you would
undertake and why?
Q. What Pathoanatomic
findings U encounter
• Age < 3m: PC mini invasive
Quad tenotomy (Dobb’s)
• Age >3mon: V-Y plasty?
• Pathoanatomy to correct?
• Position of Casting?

23. Patho-anotomy:
CKD
Quadricep tendon
contracture
Anterior subluxation of
hamstring tendon
Absent suprapatellar pouch
Tight collateral ligament

24. WHEN PRESENTED AS LONG CASE
THEN THE EXAMINER CONTINUE
IN DETAILS OF
V-Y PLASTY, COMPLICATIONS,
FOLLOWUP ETC.

25. Surgical
Procedure
Define Surgical Procedure?
• V-Y plasty?
• How to tackle Pathoanatomy?
• Position of Casting?

26. Cephalad
Right knee
Rectus femoris
Vastus lateralis
Vastus medialis

27. Rectus femoris
Vastus lateralis
Vastus medialis
Cephalad end

28. Left knee
Identify
structure

29. Identify
structur

31. Post op casting
position

34. References
• Guidelines Designed by:
DR. Sirajul Haque Shaikh,
Director DME. CPSP, Karachi.
• References:
1. Harless et al 1971
2. Cook et al, 2010.
3. Huang G, Reynolds R, Candler
C.
• Clinical Material:
Prof. Anisuddin Bhatti’s
collection
THANK YOU FOR PATIENCE