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.