Specialist & Consultant Physical Medicine & Rehabilitation oral assessment prep

Knowledge: This is autonomic dysreflexia, a medical emergency in people with spinal cord injury at or above T6. A noxious stimulus below the injury triggers unopposed sympathetic vasoconstriction, while baroreceptor-driven vagal activity causes bradycardia and flushing above the level. His baseline is low, so a rise of 20 mmHg or more is significant, and his current pressure risks intracranial haemorrhage, seizures, arrhythmia and death. Bladder distension is the commonest cause, then bowel distension, pressure injuries, ingrown toenails, tight clothing and fractures. The Consortium for Spinal Cord Medicine guideline sets a sequence: sit up, loosen clothing, find and remove the cause, then give a rapid-onset, short-acting antihypertensive if pressure stays high.

Management: I would sit him upright with legs lowered, loosen clothing, binders and leg bag straps, and check blood pressure every two to five minutes. I would catheterise him at once with lidocaine gel, or check and flush an existing catheter. If pressure stays high after drainage, I would check the rectum for faeces using lidocaine gel and examine the skin and limbs for other triggers. If systolic pressure remains markedly raised, I would give a rapid-onset, short-acting agent such as topical glyceryl trinitrate, after excluding recent phosphodiesterase-5 inhibitor use, or another agent per local protocol, watching for hypotension. If it persists, I would monitor him closely and look for hidden causes such as infection, stones, fractures or an acute abdomen. Monitoring continues for at least two hours after resolution. Afterwards I would review his bladder, bowel and skin programmes and give him a wallet card.

Ethics and communication: He and his family need education so that he can direct his own care, including in hospitals unfamiliar with the condition. A missed catheterisation is a care failure, so I would disclose it to him, apologise and report it through the incident system. Respecting his autonomy includes discussing bladder options and sexual health.

Reference: Consortium for Spinal Cord Medicine, Evaluation and Management of Autonomic Dysreflexia and Other Autonomic Dysfunctions: Preventing the Highs and Lows, Paralyzed Veterans of America, 2020; Cifu DX, Braddom's Physical Medicine and Rehabilitation (6th ed)

Knowledge: He has a severe left hemispheric stroke with probable aspiration pneumonia from unrecognised dysphagia, a hemiplegic shoulder and complications of immobility. Silent aspiration is common, so a wet voice calls for instrumental swallow assessment. The AHA/ASA guideline recommends organised interdisciplinary rehabilitation, task-specific training and early dysphagia screening. Very early, high-dose mobilisation within 24 hours was harmful in AVERT, but at day 10 he should be mobilising regularly. Intermittent pneumatic compression reduced deep vein thrombosis in immobile stroke patients in CLOTS 3. Hemiplegic shoulder pain relates to subluxation, spasticity, rotator cuff injury and complex regional pain syndrome, and poor handling makes it worse.

Management: First I would treat the chest infection, keep him nil by mouth pending speech and language therapy and instrumental assessment, and feed him by nasogastric tube. I would remove the catheter with bladder scanning, and use intermittent pneumatic compression or pharmacological prophylaxis as appropriate. For the shoulder I would teach safe handling, use positioning and supports, and treat pain, including a suprascapular nerve block if needed. Within days the team would set goals with him and his family: physiotherapy for balance, transfers and gait, occupational therapy for the arm and daily activities, and speech therapy for aphasia with supported communication. I would screen for depression and watch for spasticity. Weekly team meetings review measurable goals, and discharge planning starts early.

Ethics and communication: Aphasia does not mean he lacks capacity, so I would assess capacity for each decision using communication aids and the speech therapist's help. I would tell the family honestly that recovery is uncertain and give a realistic range rather than a date. If the delay in recognising dysphagia caused the pneumonia, I would review it through the incident process and disclose it. Family carers should be trained while his independence is encouraged.

Reference: Winstein CJ et al, Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association, Stroke, 2016; AVERT Trial Collaboration Group, Efficacy and safety of very early mobilisation within 24 h of stroke onset (AVERT), Lancet, 2015; CLOTS Trials Collaboration, Effectiveness of intermittent pneumatic compression in reduction of risk of deep vein thrombosis in patients who have had a stroke (CLOTS 3), Lancet, 2013

Knowledge: The weakness extends beyond the common fibular nerve: reduced knee flexion and a depressed ankle jerk point to a sciatic nerve injury affecting mainly the peroneal division, a recognised complication of hip arthroplasty. Normal hip abduction argues against L5 radiculopathy, because gluteus medius is supplied by the superior gluteal nerve, outside the sciatic territory. Fibular head compression and lumbosacral plexopathy from haematoma are the other differentials. At three weeks Wallerian degeneration is complete, so studies can localise the lesion and grade axonal loss through reduced motor amplitudes and fibrillation potentials. The short head of biceps femoris is the only thigh muscle supplied by the peroneal division, so needle examination of it separates a sciatic lesion from a fibular head lesion. Preserved sensory responses would suggest a root lesion instead.

Management: I would study fibular and tibial motor and superficial fibular and sural sensory nerves bilaterally. Needle examination covers tibialis anterior, tibialis posterior, gastrocnemius, short head of biceps femoris, gluteus medius and paraspinals. Nerve ultrasound or MRI can show haematoma or entrapment, which needs urgent surgical review. Meanwhile she needs an ankle-foot orthosis, physiotherapy to prevent equinus contracture, neuropathic pain treatment and foot protection. I would repeat the study at about three months to look for reinnervation. If there is no clinical or electrical recovery by three to six months, I would refer to a peripheral nerve surgeon for exploration or tendon transfer.

Ethics and communication: My report must be objective and complete, describing a likely sciatic lesion even if this is uncomfortable for a colleague. I would explain the findings honestly to her, and if she asks whether surgery caused it, I would say it is a recognised complication and encourage her to discuss it with her surgeon. Her report is released to third parties only with her consent or as the law requires.

Reference: Preston DC, Shapiro BE, Electromyography and Neuromuscular Disorders: Clinical-Electrophysiologic-Ultrasound Correlations (4th ed)

Knowledge: The Medicare Functional Classification Levels, K0 to K4, describe ambulatory potential and guide component prescription; previous indoor walking with a stick suggests K1 to K2 potential. A knee flexion contracture threatens fitting, and one beyond about 15 degrees makes a socket and efficient gait difficult. Diabetes, kidney failure and arterial disease impair healing, and the dehiscence must heal before full socket loading. The other foot is at high risk of later amputation. Phantom limb pain and residual limb pain need to be distinguished, and dialysis causes fluctuating limb volume that complicates socket fit.

Management: I would review the wound with the vascular surgeon, optimise glucose control and nutrition, and treat the dehiscence with dressings and off-loading. A rigid removable dressing or shrinker shapes and protects the limb when healing allows, and a pneumatic post-amputation mobility aid can start supervised walking if the wound permits. For the contracture I would use prone lying, stretching, no pillows under the knee and a knee extension board on the wheelchair. The left foot ulcer needs off-loading, podiatry, vascular assessment and daily inspection. I would assess cardiorespiratory fitness, cognition and transfers, then prescribe a prosthesis suited to his K-level, typically a total surface bearing socket with an appropriate suspension and foot, adjusting liners for volume changes around dialysis. Gait training, a wheelchair and home adaptation proceed in parallel, with lifelong follow-up.

Ethics and communication: Shared goal-setting matters: he may hope to walk outdoors, and I would explain what is realistic while respecting his priorities. If insurance limits the prosthesis, I would prescribe on clinical need and support an appeal rather than accept an unsafe component. Driving should be discussed with reference to the licensing authority's rules rather than my own permission. Depression and body image concerns deserve psychological support.

Reference: VA/DoD Clinical Practice Guideline for the Rehabilitation of Individuals with Lower Limb Amputation, Department of Veterans Affairs and Department of Defense; Cifu DX, Braddom's Physical Medicine and Rehabilitation (6th ed)

Knowledge: His picture is non-specific chronic low back pain without radiculopathy. Waddell signs indicate non-organic contributions and distress, not malingering, and must not be used alone to judge honesty. Impairment rating requires maximum medical improvement, which is likely at nine months after adequate treatment, and should use a standardised system such as the AMA Guides, applied as written. Impairment differs from disability or work capacity, which depend on the demands of the job. Yellow flags such as fear-avoidance and financial stress predict prolonged disability, and graded return to modified work usually helps.

Management: At the outset I would explain that I am an independent examiner, not his treating doctor, and the report goes to the insurer. I would take a full history, examine him, review records and imaging, and record findings objectively, without labels. I would rate impairment with the agreed edition of the guide and show my method. For work capacity I would describe specific, time-limited restrictions, such as lifting limits, and recommend a graded return to modified duties with a functional restoration programme rather than total incapacity. I would answer his request kindly but firmly, explaining that I cannot write something untrue, and direct him to his treating doctor, social support and the legal route for disputes. If the process allows, I would explain the report to him.

Ethics and communication: A false report would be dishonest, could expose me to liability under UAE law and undermines trust in medical evidence. I would still acknowledge his pain and financial pressure. His explicit consent to examination and release of the report must be documented, and unrelated personal information left out. If he appears depressed, I would advise him and his treating doctor.

Reference: American Medical Association, AMA Guides to the Evaluation of Permanent Impairment (6th ed); World Medical Association, International Code of Medical Ethics, 2022; Federal Decree-Law No. 4 of 2016 on Medical Liability and Cabinet Resolution No. 40 of 2019 (UAE)

Knowledge: This is acute intrathecal baclofen withdrawal, which can progress to rhabdomyolysis, disseminated intravascular coagulation, multi-organ failure and death. Early features are rebound spasticity, pruritus, agitation, tachycardia and blood pressure lability, progressing to high fever, altered consciousness and rigidity. The differential includes sepsis, autonomic dysreflexia, neuroleptic malignant syndrome, serotonin syndrome and malignant hyperthermia, and infection may coexist. Causes include an empty reservoir, catheter kink, disconnection or migration, pump failure and programming error. Oral baclofen alone is unreliable because it cannot reproduce intrathecal levels, so restoring intrathecal delivery is the definitive treatment.

Management: I would resuscitate her in a monitored bed, cool her, give fluids for rhabdomyolysis with close monitoring of kidney function and potassium, and take cultures, starting antibiotics if sepsis is possible. I would call the pump-managing physician or on-call neurosurgeon at once to interrogate, refill and check the pump programme. If the catheter may have failed, imaging and a temporary intrathecal bolus by lumbar puncture or external catheter may be needed. Meanwhile, high-dose enteral baclofen and benzodiazepines such as diazepam reduce spasms, and cyproheptadine is a recognised adjunct. If she deteriorates, she needs intensive care, sedation, ventilation and possibly dialysis. Before discharge, the whole system is checked and the refill schedule confirmed.

Ethics and communication: The missed refill is a system failure that harmed her. I would disclose it to her honestly with an apology, report it through the incident system and ensure the review covers refill scheduling, alarm education and handover when staff change. She and her family need written information on warning signs and an emergency contact. As she has capacity, consent for each intervention comes from her.

Reference: Coffey RJ et al, Abrupt withdrawal from intrathecal baclofen: recognition and management of a potentially life-threatening syndrome, Archives of Physical Medicine and Rehabilitation, 2002