SITUATION
Mr M. is a 26 year old male, who was referred to the physiotherapy department post anterior dislocation of the left shoulder and avulsion of the greater tubercle. His main complaint is pain over his anterior-lateral shoulder with movement, along with restriction of full flexion, abduction and external rotation. Mr M. is a car mechanic and has not been able to work post incident for four weeks. He states the majority of his work is underneath the cars, which means that he needs his hands above his head. This poses a problem considering he is restricted into this range and therefore not able to work. Mr M. has no red or yellow flags, with his problems seeming to be mechanical in nature and appropriate for physiotherapy intervention. Mr M. was transferred to me from a previous undergraduate physio student so therefore a thorough subjective and objective assessment is not required. Mr M. has so far been compliant with post-op surgical orders, which means you can assume he will be compliant with a post-op range of movement and strengthening program.
TASK
To complete a follow-up assessment on Mr M's asterisks signs to be able to make an accurate and relevant analysis and plan to be able to decrease Mr M's pain and improve his range.
ACTION
After introducing myself to Mr M. I asked him what I could help him with today, and establish whether he was better, same or worse since the previous physio session. Next I enquired about what his pain level were if he was in pain, and what his main concerns/ problems were. I then found out if any of the previous treatment was successful or not and whether anything new has occured since the last visit. Next was to re-asses the asterisk signs from the objective assessment of the last visit. First I observed his posture. Flexion, abduction and external rotation ranges of movements were then assessed along with his ability to put his hand behind his head and hand behind his back, giving me his P and R values. Next I palpated the painful area and the musculature around the shoulder girdle. After palpation I did a passive accessory movement assessment to see whether there was any restrictions in his joint. From there I then observed how he was performing his exercises to see whether he was getting any pain from then, and if the pain was caused by incorrect technique and whether he was ready for progression of the exercises.
RESULT
Mr M. sat with a forward chin poke, protracted scapula, increased thoracic kyphosis and decreased lumbar lordosis. On palpation Mr M has increased tone in his upper traps, levator scap, he also had positive trigger points in his anterior and posterior deltoid, long head of biceps and lat dorsi. Mr M's concordant pain was reproduced when I palpated over the deltoid insertion. Mr M's ROM are as follows:
F 100 P1
ABD 90 P1
ER WNL
Passive accessory movements showed that AP and caudad glides were hypomobile. Mr M. was also performing all exercises correctly and could be progressed to strengthening exercises.
EVALUATION
Although I performed the basic assessments, the way I conducted my assessment could have been better. I continuously got my patient into different positions to conduct my assessment. This left my assessment inefficient and time consuming, which resulted in less time for treatment. It would have no doubt been annoying for my patient also. Although this was the case, I was able to collect results from my assessments to be able to make an analysis and plan of my patients problems and possible treatments. I also would like to go through my PAMs assessment with my supervisor as I was unsure of exactly what I was feeling and what the results meant. I also need to brush up on my anatomy and I was unable to clinically reason what the concordant pain on palpation over the deltoid insertion was caused from. After consultation with my supervisor, he stated that it was likely to be cause from an inflamed bursae under the deltoid muscle.
STRATEGIES
I think making a list of all the assessments for the shoulder then dividing them into the positions you conduct them in would be helpful so I could do all of my standing assessments first, then sitting, supine and prone etc. This would then allow me to do a more efficient assessment and be more convenient for the patient, especially if they were pain dominate. Another idea would be to have a list of assessments and then during my subjective assessment crossing assessments off that are I believe would be irrelevant so I have a list of assessments I would need to conduct, and if I run out of time/ becoming short of time, I have a list i could put that in my 'review' part of my SOIER to perform on the next visit. Hopefully efficiency will come with the more practice I get.
Sunday, May 30, 2010
Sunday, May 16, 2010
STARES 1 - COMMUNICATION
SITUATION
It is Monday morning, the first day of placement and I have my first patient at Bentley Hospital in the musculoskeletal outpatients department. My patient is Mr P, a 52 year old that has been referred by his GP with CLBP with bilateral anterior thigh cramping and foot weakness when walking. He has had the low back pain for 5 years now and is under the care of the pain management clinic at SCGH. The referral states that the back pain and thigh numbness are his main concern. There are no pins or needles or numbness and radiological investigations show no abnormalities are detected. Mr P is borderline diabetic which could be contributing to his foot weakness, but apart from that has no other health issues. Mr P lives with his wife and two adult children. He migrated from India 7 years ago and works full time for BP, where he is a customer consultant, which consists of him meeting clients throughout the day where he states he ‘hardly ever gets to sit down’. This is all the information that was given with the handover. He was referred for physiotherapy for treatment of his CLBP and thigh cramping.
TASK
In the hour and a half available it was my duty to complete a full subjective assessment which would allow me to be able to complete an appropriate objective assessment which then from my findings, carry out an individualised treatment for Mr P.
ACTION
With Mr P’s referral handover in my file, I went out to the waiting room to meet Mr P. This is where my informal assessment began. When I called his name I assessed how he performed the tasks of sit-stand and walking. I then introduced myself and asked him to take a sit in the third cubicle. This is where I lagged behind him to do an informal assessment of his gait, to see whether he had an antalgic gait or postures. Once seated I informally assess his sitting posture. I then begin my subjective assessment with my body chart starting from his worst, most limiting pain and working my way to his best, manageable pain questioning about their VAS score and qualities and establishing whether he complained of any pins or needles or numbness. After completing all the components of the body chart I then moved onto the rest of the subjective assessment. This included obtaining the current history of Mr P’s pains. Next was establishing the aggravating factors, easing factors, irritability then the behaviour of the pain throughout the course of the day including the morning and during the night. Next was to question Mr P in regards to his any related past history, previous treatment, social history and general health. General health includes any disorders (for example diabetes), medications (steroids, anticoagulants), previous surgery, weight loss, dizziness and cauda equina symptoms which will expose any possible red flags to physiotherapy treatment. This concluded the subjective assessment, at this point I was to leave my patient to discuss with my supervisor what my findings were and what an appropriate objective assessment would consist of.
RESULTS
After my subjective assessment of Mr P, I was left with a very messy and full assessment sheet. Mr P had seven pains that he described. Once I introduced myself the first thing I asked was along the lines of ‘What can I help you with?’ I was then bombarded with every problem that he was facing at that time. This really caught me off guard and freaked me out a little, because all I was thinking was I have no idea what is wrong with this patient. Thankfully I had the musculoskeletal assessment sheet and I attempted to ask about his worst pain. Mr P then responded with his lower back pain yet continued to go on about his other pains and I found it very difficult to keep him on track. As much as I tried to keep him on track, it was very difficult and he also responded with inappropriate answers due to his limited English, which made finding out his description of the pain etc to be very difficult. What I did manage to obtain was this.
Pain A – low back pain, constant dull ache 7/10 – 10/10
Pain B – sharp pulling pain down both posterior legs, constant 4/10 – 7/10
Pain C – mid thoracic pain constant dull ache 5/10-8/10
Pain D – numbness in the ant thigh, intermittent 4/10 – 7/10
Pain E – neck pain constant dull ache 6/10 – 9/10
Pain F – pulling pain into the hands 2/10 – 5/10
Pain G – numbness in feet, intermittent 3/10 – 7/10
Pain A can come on alone
Pain B can come on alone or when pain A is severe
Pain C can come on alone
Pain D comes on with Pain A
Pain E can come on alone
Pain F only come on with pain E
Pain G can come on alone, with Pain A and with Pain A + B
7 years ago, Mr P sustained severe burns to 92% of his body, where afterwards spent 52 days in ICU and then 127 further days in and out of surgery to repair his skin with grafts. Pain A, C and E began while he was in hospital. The leg and arm symptoms have only started within the last 5 months.
Mr P was very vague with the aggravating factors and stated that he hasn’t noticed what really brings it on. Easing symptoms include leaning forward and lying down. The pain is worse in the morning (first thing) and wakes him up at night, and it takes him around 30 minutes to get back to sleep. Mr P states he has not had a proper night sleep since sustaining the burns. Mr P had no other surgeries apart the ones that dealt with his skin grafts. His general health was good apart from being borderline diabetic and investigations (X-rays) showed no pathologies. Mr P was very active before he sustained the burns, but since then cannot exercise much due to the pain, but does work full time.
EVALUATION
I think nerves played a big role in this task considering it was my first real musculoskeletal patient. It also didn’t help that the patient was quite complex, complaining of multiple pains with some form of neural input. I found it very difficult to direct Mr P with my questioning for him to answer how I wanted him to and perhaps with the answers I was searching for. This meant that the subjective questioning went on a lot longer than it should have as I was constantly trying to get back on track and follow the questioning order that I was used to from class. As my subjective went too long, I had limited time to do a proper objective assessment and therefore be confident in diagnosing Mr P as being suitable for physiotherapy and tailoring an individualized treatment program for him.
STRATEGIES
I need to work on asking questions that will keep my patients on track and actually get them to give me the answer I am looking for. Closed questions are what I need to work on. I also need to have the courage to speak up to the patient if I feel they are giving me information that is not relevant so that I don’t waste time and get lost with what I was trying to achieve with my patient. As my patient spoke English, but in some areas he struggled to convey his meaning (especially in regards to describing his pain), leading questions would have been appropriate and I need to work these into my subjective questions. I believe, with practice I will be able to refine my subjective questioning and work out what questions work in getting the response I want.
It is Monday morning, the first day of placement and I have my first patient at Bentley Hospital in the musculoskeletal outpatients department. My patient is Mr P, a 52 year old that has been referred by his GP with CLBP with bilateral anterior thigh cramping and foot weakness when walking. He has had the low back pain for 5 years now and is under the care of the pain management clinic at SCGH. The referral states that the back pain and thigh numbness are his main concern. There are no pins or needles or numbness and radiological investigations show no abnormalities are detected. Mr P is borderline diabetic which could be contributing to his foot weakness, but apart from that has no other health issues. Mr P lives with his wife and two adult children. He migrated from India 7 years ago and works full time for BP, where he is a customer consultant, which consists of him meeting clients throughout the day where he states he ‘hardly ever gets to sit down’. This is all the information that was given with the handover. He was referred for physiotherapy for treatment of his CLBP and thigh cramping.
TASK
In the hour and a half available it was my duty to complete a full subjective assessment which would allow me to be able to complete an appropriate objective assessment which then from my findings, carry out an individualised treatment for Mr P.
ACTION
With Mr P’s referral handover in my file, I went out to the waiting room to meet Mr P. This is where my informal assessment began. When I called his name I assessed how he performed the tasks of sit-stand and walking. I then introduced myself and asked him to take a sit in the third cubicle. This is where I lagged behind him to do an informal assessment of his gait, to see whether he had an antalgic gait or postures. Once seated I informally assess his sitting posture. I then begin my subjective assessment with my body chart starting from his worst, most limiting pain and working my way to his best, manageable pain questioning about their VAS score and qualities and establishing whether he complained of any pins or needles or numbness. After completing all the components of the body chart I then moved onto the rest of the subjective assessment. This included obtaining the current history of Mr P’s pains. Next was establishing the aggravating factors, easing factors, irritability then the behaviour of the pain throughout the course of the day including the morning and during the night. Next was to question Mr P in regards to his any related past history, previous treatment, social history and general health. General health includes any disorders (for example diabetes), medications (steroids, anticoagulants), previous surgery, weight loss, dizziness and cauda equina symptoms which will expose any possible red flags to physiotherapy treatment. This concluded the subjective assessment, at this point I was to leave my patient to discuss with my supervisor what my findings were and what an appropriate objective assessment would consist of.
RESULTS
After my subjective assessment of Mr P, I was left with a very messy and full assessment sheet. Mr P had seven pains that he described. Once I introduced myself the first thing I asked was along the lines of ‘What can I help you with?’ I was then bombarded with every problem that he was facing at that time. This really caught me off guard and freaked me out a little, because all I was thinking was I have no idea what is wrong with this patient. Thankfully I had the musculoskeletal assessment sheet and I attempted to ask about his worst pain. Mr P then responded with his lower back pain yet continued to go on about his other pains and I found it very difficult to keep him on track. As much as I tried to keep him on track, it was very difficult and he also responded with inappropriate answers due to his limited English, which made finding out his description of the pain etc to be very difficult. What I did manage to obtain was this.
Pain A – low back pain, constant dull ache 7/10 – 10/10
Pain B – sharp pulling pain down both posterior legs, constant 4/10 – 7/10
Pain C – mid thoracic pain constant dull ache 5/10-8/10
Pain D – numbness in the ant thigh, intermittent 4/10 – 7/10
Pain E – neck pain constant dull ache 6/10 – 9/10
Pain F – pulling pain into the hands 2/10 – 5/10
Pain G – numbness in feet, intermittent 3/10 – 7/10
Pain A can come on alone
Pain B can come on alone or when pain A is severe
Pain C can come on alone
Pain D comes on with Pain A
Pain E can come on alone
Pain F only come on with pain E
Pain G can come on alone, with Pain A and with Pain A + B
7 years ago, Mr P sustained severe burns to 92% of his body, where afterwards spent 52 days in ICU and then 127 further days in and out of surgery to repair his skin with grafts. Pain A, C and E began while he was in hospital. The leg and arm symptoms have only started within the last 5 months.
Mr P was very vague with the aggravating factors and stated that he hasn’t noticed what really brings it on. Easing symptoms include leaning forward and lying down. The pain is worse in the morning (first thing) and wakes him up at night, and it takes him around 30 minutes to get back to sleep. Mr P states he has not had a proper night sleep since sustaining the burns. Mr P had no other surgeries apart the ones that dealt with his skin grafts. His general health was good apart from being borderline diabetic and investigations (X-rays) showed no pathologies. Mr P was very active before he sustained the burns, but since then cannot exercise much due to the pain, but does work full time.
EVALUATION
I think nerves played a big role in this task considering it was my first real musculoskeletal patient. It also didn’t help that the patient was quite complex, complaining of multiple pains with some form of neural input. I found it very difficult to direct Mr P with my questioning for him to answer how I wanted him to and perhaps with the answers I was searching for. This meant that the subjective questioning went on a lot longer than it should have as I was constantly trying to get back on track and follow the questioning order that I was used to from class. As my subjective went too long, I had limited time to do a proper objective assessment and therefore be confident in diagnosing Mr P as being suitable for physiotherapy and tailoring an individualized treatment program for him.
STRATEGIES
I need to work on asking questions that will keep my patients on track and actually get them to give me the answer I am looking for. Closed questions are what I need to work on. I also need to have the courage to speak up to the patient if I feel they are giving me information that is not relevant so that I don’t waste time and get lost with what I was trying to achieve with my patient. As my patient spoke English, but in some areas he struggled to convey his meaning (especially in regards to describing his pain), leading questions would have been appropriate and I need to work these into my subjective questions. I believe, with practice I will be able to refine my subjective questioning and work out what questions work in getting the response I want.
Sunday, May 9, 2010
Intial entry
Tomorrow I'll be starting my musculoskeletal placement at Bentley Hospital's outpatient department. After the orientation session on Monday I have become quite nervous for this placement. A reason for this is because I've never had a placement before that was in an outpatient setting, so I am a little anxious about how I will go in this new field. It will be a completely new experience for me, especially regarding communication with patients as I am used to taking a subjective from a patient in a hospital bed. Although daunting for me as it is my first time in this area, I am a little excited because since day one I have always ultimately seen myself working in an outpatient environment in my career. I think my main concern is being able to take a comprehensive subjective and from that pick out the main objective assessments I would want to do with that client and then from that form a diagnosis and then an appropriate individualised treatment - all without a '15 minute reading time'. I am worried about this because it will be completely different from the musculoskeletal practical exams, which I am used to, and I will have a variety of clients in one day not just 'lumbar spine' or 'upper limb' like we did for our practical exams.Throughout this week I have also found it difficult in regards to revision as I felt so overwhelmed and didn't really know where to start. I did do an anatomy refresher, but in this I realised how little I remembered and I think this made me even more nervous.
I am glad that Lillie will be on this placement with me as we get on really well and I’m sure she can help me with any patients that I may be having trouble with. I am also glad that I had the opportunity of meeting our supervisor on our orientation day as I think that has taken off some of the edge of starting placement because I remember from previous placements my main concern was whether the supervisor will be nice and approachable. Rhod seemed extremely nice and outgoing from my encounter with him on Monday and I am very excited to be on placement with him as he seems to have a lot of experience in the area and will be a great source of information.
Taya, who was previously on this placement says that you get a lot of freedom with your clinical time. This will also be a new experience for me as on previous placements for the majority of the beginning weeks the supervisor has been with me, whereas on this placement, I won't be watched through my sessions. This concerns me a little as I won't have someone there to help me with my handling techniques and to tell me I am doing something wrong. What also concerns me about this is whether I will be learning a lot as I don't have a tutor to go through patients with me either.
I know I will enjoy this placement because I find this field of physiotherapy very interesting. So as much as I am nervous I am also very excited as it will be my first experience of what I feel I ultimately want to do with my degree, so hopefully I will enjoy it! All I need to do know is to make sure I manage to get through the peak hour traffic to get there on time!
I am glad that Lillie will be on this placement with me as we get on really well and I’m sure she can help me with any patients that I may be having trouble with. I am also glad that I had the opportunity of meeting our supervisor on our orientation day as I think that has taken off some of the edge of starting placement because I remember from previous placements my main concern was whether the supervisor will be nice and approachable. Rhod seemed extremely nice and outgoing from my encounter with him on Monday and I am very excited to be on placement with him as he seems to have a lot of experience in the area and will be a great source of information.
Taya, who was previously on this placement says that you get a lot of freedom with your clinical time. This will also be a new experience for me as on previous placements for the majority of the beginning weeks the supervisor has been with me, whereas on this placement, I won't be watched through my sessions. This concerns me a little as I won't have someone there to help me with my handling techniques and to tell me I am doing something wrong. What also concerns me about this is whether I will be learning a lot as I don't have a tutor to go through patients with me either.
I know I will enjoy this placement because I find this field of physiotherapy very interesting. So as much as I am nervous I am also very excited as it will be my first experience of what I feel I ultimately want to do with my degree, so hopefully I will enjoy it! All I need to do know is to make sure I manage to get through the peak hour traffic to get there on time!
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