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OR14.1-4 | Counselling and Rehabilitation Skills — Practice Quiz
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A 35-year-old labourer sustains a comminuted fracture of both bones of the leg requiring intramedullary nailing. After surgery, he asks the orthopaedic intern: 'Doctor, will I be able to walk normally and return to work?' Which framework best structures this prognosis counselling conversation?
Correct. SPIKES (Setting-up, Perception, Invitation, Knowledge, Emotions/Empathy, Summary/Strategy) is the standard structured protocol for prognostic counselling. It respects autonomy while managing emotional distress through incremental, invitation-based disclosure.
The SPIKES protocol (Setting, Perception, Invitation, Knowledge, Emotions, Strategy) provides a structured, patient-centred approach to breaking difficult news and discussing prognosis, including functional recovery timelines and realistic return-to-work expectations.
The SPIKES protocol is the correct framework. It begins by assessing what the patient already knows, invites them to receive information, delivers it incrementally, addresses emotional responses empathically, and concludes with a clear management strategy.
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You are counselling a 60-year-old farmer with a closed femoral neck fracture (Garden III) about the need for hemiarthroplasty. He lives in a remote village with no caregiver. Which element of valid informed consent is MOST likely to be inadequately addressed if you proceed after only a brief verbal explanation?
Correct. Comprehension — the patient's actual understanding of what they have been told — is most at risk in elderly, low-literacy, or isolated patients receiving a brief verbal explanation. Health literacy assessment and 'teach-back' are essential.
Valid informed consent requires competence, adequate information (diagnosis, procedure, risks/benefits, alternatives), comprehension, and voluntariness. In elderly, illiterate, or isolated patients, comprehension is most at risk; assessing understanding by asking the patient to re-explain in their own words is essential.
While all consent elements are important, comprehension is most likely to be inadequate when only a brief explanation is given to a patient with likely low health literacy and no support person present.
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A 14-year-old presents with a 5-day history of fever, localised tenderness over the distal femur metaphysis, and a warm swollen knee. Blood culture is pending. His mother wants to manage him with oral antibiotics at home. Which finding is the MOST compelling warning signal to convince her that hospital admission and IV antibiotics are essential?
Correct. Localised metaphyseal tenderness with high fever and elevated inflammatory markers are warning signals of acute osteomyelitis. Delayed or inadequate treatment risks subperiosteal abscess, septicaemia, epiphyseal damage, and chronic osteomyelitis — the clinical argument for urgent referral.
Acute haematogenous osteomyelitis in children can progress to septicaemia, subperiosteal abscess, and chronic osteomyelitis within days. High fever, localised metaphyseal tenderness, and elevated inflammatory markers constitute warning signals mandating urgent hospital referral and IV antibiotics.
The medical warning signals — bony tenderness, systemic toxicity, and the risk of progression to abscess and chronic disease — are the compelling clinical reasons for referral, not logistical or social factors.
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A 28-year-old man with a 6-week history of low back pain now reports progressive bilateral leg weakness, difficulty initiating micturition, and saddle anaesthesia. The peripheral health worker wants to continue physiotherapy. What is the MOST important red flag to communicate when convincing the patient to seek urgent referral?
Correct. Cauda equina syndrome triad (bilateral motor weakness, sphincter disturbance, saddle anaesthesia) demands emergency referral within hours. Delay beyond 24–48 hours is associated with permanent bladder/bowel dysfunction and paralysis — this must be clearly communicated to the patient.
Cauda equina syndrome (bilateral leg weakness + bladder dysfunction + saddle anaesthesia) is a surgical emergency. Delay beyond 24–48 hours risks permanent sphincter dysfunction and paralysis. This constitutes an absolute red flag demanding immediate referral for emergency MRI and decompression.
This clinical triad constitutes cauda equina syndrome, a neurosurgical emergency. Immediate MRI and surgical decompression within 24–48 hours are required; delay causes irreversible neurological damage.
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A 45-year-old woman with rheumatoid arthritis has severe right knee septic arthritis on aspiration (turbid fluid, glucose <2.2 mmol/L, WBC 85,000 cells/µL). You recommend admission and arthrotomy. She is worried about the 'operation' and wants to try antibiotics alone first. What is the key warning signal argument to convince her to accept surgical management?
Correct. Purulent septic arthritis requires surgical drainage because leucocyte-released proteolytic enzymes (collagenase, elastase) destroy articular cartilage within 24–48 hours. This irreversible damage is preventable only by prompt joint decompression — the key argument for convincing the patient.
Septic arthritis with purulent joint fluid requires urgent surgical drainage (arthrotomy or arthroscopic washout) in addition to antibiotics. Delayed drainage allows proteolytic enzyme destruction of articular cartilage within 24–48 hours, leading to irreversible joint damage and osteomyelitis.
The key warning signal is cartilage destruction by proteolytic enzymes released by pus, which occurs within 24–48 hours if drainage is not performed. Antibiotics alone cannot adequately penetrate thick pus to sterilise the joint.
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A 52-year-old diabetic with a crush injury to the right foot undergoes below-knee amputation. Post-operatively you counsel him about phantom limb pain. Which statement MOST accurately describes the pathophysiology and management of this condition?
Correct. Phantom limb pain is a genuine neuropathic pain, not psychological. The mechanism involves peripheral neuroma activity, spinal sensitisation, and cortical reorganisation. Mirror therapy, gabapentinoids, and early prosthetic fitting are evidence-based treatments.
Phantom limb pain is a real neuropathic pain arising from cortical reorganisation and persistent peripheral/central sensitisation after amputation. It is NOT psychological. First-line treatments include mirror therapy, gabapentinoids (gabapentin, pregabalin), tricyclic antidepressants, and early prosthetic fitting.
Phantom limb pain is a real, neurobiologically-based neuropathic pain. It does not indicate surgical pathology and is not primarily psychological. Mirror therapy and gabapentinoids are first-line treatments.
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A below-knee amputee is being fitted for a prosthesis. Which prosthetic socket type is most commonly used for below-knee (transtibial) amputees and transmits body weight through which anatomical structure?
Correct. The PTB (Patellar Tendon Bearing) socket is the standard below-knee prosthetic socket. It bears weight primarily through the patellar tendon and is contoured to relieve pressure over the tibial crest, fibular head, and tibial flares.
The Patellar Tendon Bearing (PTB) socket is the standard socket for below-knee amputees. It transfers weight primarily through the patellar tendon and the anterior compartment of the residual tibia, while relieving pressure over sensitive bony prominences like the tibial crest and fibular head.
The PTB (Patellar Tendon Bearing) socket is the standard socket for below-knee (transtibial) amputees, transmitting weight primarily through the patellar tendon.
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In below-knee amputation for severe peripheral vascular disease, which level of amputation typically provides the best balance between healing potential and adequate residual limb length for effective prosthetic fitting?
Correct. The optimal transtibial amputation preserves 12–15 cm of tibia from the tibial tuberosity. This length provides enough leverage and surface area for PTB socket fitting while maintaining a well-vascularised flap for wound healing.
The ideal below-knee (transtibial) amputation level preserves 12–15 cm of tibial length from the tibial tuberosity, ensuring adequate soft tissue for a well-padded stump and preserving the knee joint for maximal prosthetic rehabilitation potential. Too short a stump limits prosthetic control; too long risks ischaemic wound healing failure.
12–15 cm of tibial length from the tibial tuberosity is the standard recommended level for below-knee amputation, balancing wound healing, muscle coverage, and prosthetic fitting.
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