- The document describes a virtual clinical examination tool called Interactive Paper Patients (IPPs) that allows students to examine and manage simulated patients in a structured question-and-answer format with an examiner. - An example is provided of a case involving a 2-week old infant with clinical findings suggestive of congenital knee deformity. The examiner guides the student through the case by revealing details in phases and asking questions to assess understanding. - In later phases, the student is shown x-rays, asked to interpret findings and propose management, which may involve non-operative or operative treatment such as a V-Y plasty procedure to correct pathoanatomy like quadriceps contracture.

1. VIRTUAL CLINICAL
EXAMINATION
“INTERACTIVE PAPER
PATIENT”
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
• Clinical examination, however, requires a linear
dialogue between examiner and examinee, for
which VPs need to be adapted accordingly

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.

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
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
Q. What specific surgical
procedure you would
undertake and why?
Q. What Pathoanatomic
findings U encounter
• V-Y plasty?
• Pathoanatomy to
correct?
• Position of Casting?

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

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

25. Cephalad
Right knee
Rectus femoris
Vastus lateralis
Vastus medialis

26. Rectus femoris
Vastus lateralis
Vastus medialis
Cephalad end

27. Left knee
Identify
structure

28. Identify
structur

30. Post op casting
position