SMALL GROUP SESSION 21B February 10 th or February 12 th Lower Extremity Examination and Ethics Case Discussion Suggested Readings: Opatrny L. The Healing Touch. Ann Int Med 2002; 137:1003. http://www.annals.org/cgi/reprint/137/12/1003.pdf Complete the web modules: Principles of Musculoskeletal Exam and the Lower Extremity Exam Mosby s Guide to Physical Diagnosis- Chapter on Lower Extremity Prepare by: Wearing clothing for examining each others lower extremities (tank tops, loose T-shirts, gym shorts). Someone should bring anatomy text and atlas. It will be helpful! Brief Outline: Section 1 Touch Base (10 minutes) Section 2 Section 3 Case Discussion: Withholding Tube Feeding in a Woman with Advanced Dementia (80 minutes) Lower Extremity Exam (80 minutes) Section 4 Evaluate Session (10 minutes). 1
Objectives for Session 21B: By the end of the session, students will be able to: Identify the major ethical issues involved in withdrawing medical treatment Demonstrate physical examination of the lower extremity Demonstrate and describe the significance of the following components of the knee exam: Lachman test and anterior drawer tests posterior drawer tests varus and valgus stress McMurray test Section 1 Touch Base (10 minutes) Your exams are next week? Do you feel prepared? Section 2 Ethics Case Discussion (80 minutes) Logistics: Mentors hand out or view the case with the projector. One student should read the case and the group should discuss Withdrawing Tube Feeding in a Woman with Advanced Dementia Mrs. V is an 88 year old woman with advanced dementia who lives in a nursing home. As her dementia progressed she was able to take less and less food by mouth and percutaneous endoscopic gastrostomy (PEG) was performed for total enteral nutrition and hydration. Mrs. V is now mute, bedridden, incontinent, and completely dependent. She moans at times, occasionally scratches herself, and pulls at her feeding tube. Wrist restraints and padded mitts have been applied periodically to prevent her from dislodging the tube. Mrs. V was diagnosed with Alzheimer s dementia nine years ago. Except for mild hypertension and intermittent pressure sores, she currently has not other illnesses. In the past three years, however, she has been hospitalized with pneumonia on four occasions, but she improved rapidly with systemic antibiotics. Although Vivian s niece originally authorized the feeding tube, she is distressed at her aunt s condition and now requests that tube feeding be discontinued, but the nursing home refuses. The niece insists, stating that her aunt once said, If I ever get senile, I hope they shoot me, and that she would never have wanted this type of treatment in her condition. The nursing home rejects the notion that this is treatment at all; they believe that the feeding tube is basic care that should be provided, and that not to do so would be a failure to meet the standard of care in such institutions. The physician says that not to do so would amount to starving the patient to death. Furthermore, the physician points out, the patient 2
has hypoalbuminemia, pressure ulcers, and susceptibility to aspiration pneumonia, making the feeding tube strongly indicated. Questions for discussion: 1. What ethical differences are there, if any, between tube feeding and other medical treatments? The prevailing ethical and legal consensus is that tube feeding is essentially a medical treatment, and that patients with intact decisional capacity have a right to refuse any and all medical treatment(s).it is important to point out, however, that some religious groups and individuals maintain that tube feeding is not really medical treatment, but rather a more basic human need that must be met by anyone caring for an incapacitated patient. This may be the reason cited for not allowing tube feeding to be withheld or stopped. 2. Is there an ethical difference between deciding not to provide tube feeding and stopping it after it has been started? Ideally, risks and benefits of tube feeding should be discussed with patients or their surrogates before the crucial need arises, but if tube feeding has been started, and there is no evidence that it has improved the overall situation, it is usually ethically defensible to withdraw it. The emphasis here should be on clear communication to the patient or surrogate about risks/benefits in the context of the ongoing total situation, as well as serious attention to the preferences of the patient, to the extent that they can be known. 3. How should the physician in this case respond to the niece s I hope they shoot me, anecdote? You might encourage the niece to talk about other, perhaps more extensive, conservations she or others had had with the patient. Obviously, the physician cannot interpret the patient s words literally, so what did she really intend to convey with these words? Such conversations do have both ethical and legal weight and importance, but the more detail the better, i.e. would her preferences be different if she was senile and in poor physical health? Did she know of anyone who was receiving such treatment and what did she think about it? This case provides a good opportunity to remind the students that ethical dilemmas like this rarely have one clear right answer, and that the goal is to find the most ethically defensible solution(s) that appear to be in line with what we know about the patient s preferences. 3
Section 3: Lower Extremity Examination (80 minutes) EXTREMITY EXAMINATION Review the following characteristics assessed during a musculoskeletal exam: range of motion signs of inflammation (redness, warmth, swelling, pain) crepitus deformities condition of surrounding tissues muscular strength symmetry Review the techniques used to evaluate the joints and surrounding soft tissues: inspection active range of motion palpation passive range of motion strength testing special maneuvers LOWER EXTREMITY EXAMINATION Exam: 1. The hip and pelvis: assess strength: ask patient to stand from a sitting position inspect for symmetry, deformity and discoloration while standing palpate surface landmarks: palpate the iliac crest and greater trochanter do passive range of motion: abduction, adduction, flexion, extension, internal rotation, external rotation of the hip 2. The knee: inspect for symmetry, deformity and discoloration palpate for swelling or tenderness along the joint lines, the patella and the popliteal space. Palpate for crepitus during motion do range of motion: flexion and extension assess strength: have patient flex and extend knee against resistance Maneuvers of the knee o Assess mediolateral instability: support leg and stabilize knee. Apply a varus and valgus stress, and evaluate the lateral and medial collateral ligaments, respectively, for pain or laxity o Assess cruciate ligament: Flex knee to 30 (Lachmann) or to 90 (anterior drawer), stabilize the lower leg, and pull the lower leg towards you and watch for anterior movement of the tibia. With the leg flexed to 4
90 and while stabilizing the lower leg, push the lower leg towards the patient while assessing for posterior movement of the tibia (posterior drawer). o Assess meniscal cartilage (McMurray test): flex knee and hip, support knee with one hand. With other hand internally rotate and extend knee, then flex knee and externally rotate and extend knee. Feel for pain and/or a popping sensation. o 3. The foot and ankle: inspect for symmetry, deformity and discoloration palpate Achilles tendon, lateral and medial malleoli and mid-foot and forefoot. do range of motion: extension (plantar flexion), flexion (dorsiflexion), inversion (adduction) and eversion (abduction). assess strength: have patient plantar flex, dorsiflex, evert and invert foot against resistance. Section 4: Evaluate Session (10 minutes) How did this session go? 5
Lower Extremity A = Attempted Satisfactory B = Attempted Below Satisfactory C = Did Not Attempt Procedure A B C Comments 1. INSPECTION: a. Examiner assesses strength of proximal hip muscles by asking patient to rise from chair. b. Examiner assesses hips, knees, ankles and feet for symmetry, deformity and discoloration while patient is standing. 2. HIP Palpate: Ex should palpate iliac crest and greater trochanter. 3. HIP Range of motion: (Passive) a. Flexion with the patient supine, the ex should flex the patient s hip with knee bent. b. Extension (prone or standing) ex should extend patient s hip. c. Adduction and abduction with patient supine, ex should adduct and abduct patient s hip. d. Internal and external rotation with patient supine and knee flexed to ~90, ex should internally and externally rotate patient s hip. 4. KNEE Inspect: Ex inspects knee with patient supine for swelling and discoloration. 5. KNEE Palpate: Ex should palpate popliteal space, tibiofemoral joint space laterally and medially, and patella. 6. KNEE Range of motion: Ex asks patient to flex and extend knee. 7. KNEE Strength: Ex should resist patient while patient flexes and extends knee. 8. KNEE Special maneuvers (not required): a. Mediolateral instability Ex should flex knee to 30, apply varus and valgus stress to knee, assessing for medial and lateral laxity. b. Cruciate ligament: Lachman test Ex should flex knee to 20 to 30, grasp the distal thigh above the patella with one hand (thumb should wrap over thigh just above patella), grasps proximal tibia with other hand and pulls tibia anteriorly. OR Cruciate ligament: Drawer test Ex should flex knee to 90, stabilize foot by lightly sitting on it, and pull tibia anteriorly for anterior drawer test, and also push posteriorly for posterior test. (Ex may choose which cruciate test to perform ex is responsible for only one of these.) c. McMurray test (included only for small group use, not for testing) Ex should flex knee completely, encircle joint space with thumb and index finger, rotate foot laterally, and extend knee. Maneuver should be repeated with medial 6
rotation of foot. 9. ANKLE and FOOT Inspection: Ex should inspect for swelling and discoloration. 10. ANKLE and FOOT Palpation: Ex should palpate achilles tendon, lateral and medial malleoli and forefoot. 11. ANKLE and FOOT Range of motion: Ex should ask patient to dorsiflex, plantar flex, evert and invert the ankle. 12. ANKLE and FOOT Strength: Ex should resist patient while patient dorsiflexes and plantar flexes ankle. Ex also resists inversion and eversion. 7