Situation
On my 3rd week of my placement, on the 25/04/10 I was asked to assess and treat an 81 year old lady who had been referred by a neurologist for nerve compression. This was my first patient I had treated in this placement that had a nerve compromise problem. I was quiet nervous about treating this lady.
This 81 year old woman had had a past medical history of 2 laminectomys ( in 2008 and 2009) a double mastectomy, a hysterectomy and a fracture to her right femur (06). She also had type 2 diabetes melinitis and hypertension that was being managed medically.
This lady lived alone, and was managing her activities of daily living independently, she was receiving no outside help from other services although her daughter occasionally helped out this lady with meals and laundry jobs.
With this lady’s referral came information about an x-ray she had performed on her neck on the (20/05/2010), the x-ray outlined that C4/C5 joint on the right had osteophytes that were crowding the joint and possibly causing nerve compression to nerve root 4. The neurologist asked if I could help treat this woman’s symptoms.
Task
I performed a subjective and objective assessment of this lady and based on my findings I established an appropriate treatment plan for her problems that I identified through my assessment.
Action
I performed my subjective assessment, asking here where her pins and needles were, in what distribution she felt them, how she would describe her pain etc. I then asked her about what activities brought on her pins and needles and how long they took to ease. I also cleared her for all other sinister (red flags) possible diseases or complications.
I then performed my objective assessment, testing her sensation (light touch and sharp/blunt discrimination) her muscle power and her reflexes.
Result
Through my assessment I found she was having pins and needles on the top of her shoulder, the pins and needles didn’t radiate down the arm but stuck on the shoulder, I found she had difficulty raising the arm above her head to put on her shirts, and clothing and it took a long time for the pins and needles and numbness to dissipate.
In addition to this I found her shoulder shrug was weaker on the right side than the left, which would support the theory of the nerve root 4 compromise. I also found she had altered sensation around the anterior shoulder and posterior arm which could also indicate nerve root 4 compromise. She also had hypersensitivity and muscle spasm in the area just medial to her scapula and bellow it as well. I found no problems with her reflexes.
Through this examination I then tried to open up the foramen of C4/C5 to help try to free nerve root 4.
Evaluation
I don’t think I performed this assessment too well, Although I performed all the necessary assessment techniques for nerve root compromise ( reduced/altered sensation, reduced muscle power and reduced reflexes), and I did establish her problem area I don’t think I performed them in a completely accurate way.
In addition I didn’t clear her thoracic spine for any involvement in that area, the next time I saw this lady, my supervisor and I established that she had nerve root T1 involvement as well, She had a stiff 1st rib on the right side which was also contributing to her problem.
Although the neurologist had only referred her for cervical radiculopathy, this lady had involvement of her thoracic spine as well.
Strategies
I worked out a few strategies that would help me when testing for nerve root compromise next time, Hopefully these will help me perform a more accurate assessment when diagnosing a patients nerve root level.
1. When performing sensation testing for nerve roots, try to test the sensation of the skin which corresponds to the dermatome position for the nerve root, so that I can establish a clear understanding of which nerve root has been compromised. In addition using a chart in front of me while performing the sensation test, just to jog my memory of where exactly the dermatomes are on the body.
2. When performing muscle tests try to perform left and right sides together if this is possible ( to get the most accurate measurement) if not, try to perform them straight after one another.
3. Always clear the joint above and bellow the affected area, in this case I should have cleared her thoracic spine and possibly her shoulder joint for any problems in those areas.
4. Use a neurodynamic test for one of the nerves to take a baseline for the patient’s irritability, use this when treating the patient to see if their symptoms improve.
Sunday, May 30, 2010
Sunday, May 16, 2010
WEEK 1
Situation
On Wednesday (12/05/2010) in the first week of my placement I was asked to assess and treat a 65 year old woman. This woman had come in to the Swan Districts outpatient’s physiotherapy department needing therapy for her right total knee replacement (TKR) that was performed three weeks ago on the 22/04/2010. This woman had complications after her TKR that included a clot in her left lung and DVT complications. On discharge, it was noted in her referral form, that her right quads lag was -200 and her right knee flexion was 750 . There was no other information given on her referral form.
I greeted this lady in the waiting area and asked her to come through into the treatment room, she was ambulating on two elbow crutches.
My supervisor was not going to come into the room with me but he was simply going to check with me after the assessment and treatment to see that I was on the right track.
Task
My task was to perform a subjective and objective assessment of this woman and work out an appropriate treatment plan to address any impairment’s that I might find in her assessment.
Action
I performed a subjective and objective assessment on this lady, I asked her a number of questions and tested her range of motion and strength of both her lower limbs. I found that she now had a quads lag of 300 and knee flexion of 750 . I then tailored my treatment towards increasing her range of motion for knee flexion and strengthening up her quadriceps muscles.
Result
The lady understood her programme and was happy to comply with it. The session addressed her impairments of decreased right knee flexion and decreased strength in her right leg, so it was beneficial in this way. However there were some components of my subjective assessment that needed extra work to make sure I had an accurate description of her situation.
Evaluation
I think there were some strengths in my session with this woman ; I think I performed my treatment well, and I gave her a easy exercise programme to follow at home. I think I went through the programme thoroughly with her and gave her an opportunity to ask any questions of me, making sure she understood the programme well.
I think there were some weaknesses in my session; I don’t think the subjective assessment went too well, I had to clarify some of my questions a couple of times so the patient understood what I was saying. I also forgot to ask my patient some questions that were impertinent to ask. In addition I thought that sometimes I asked questions that lead the patient to respond in a certain way; ie I influenced their answer. I think I also took a very long time with this patient; the whole session took an hour and a half.
Strategies
I worked out appropriate strategies to make sure that next time I was going to assess a patient I could perform a thorough and comprehensive subjective assessment.
1. Make sure the questions that I ask are open ended questions; where the patient can talk; giving them an opportunity to impart all their information. Also to refrain from using closed questions, where the patient only answers yes or no.
2. Make sure that my questions are not leading in anyway, that my questions do not influence my patients answer.
3. Use the prompts on the assessment sheet to make sure I don’t forget to ask any important questions.
4. Be aware when to redirect the conversation in a respectful and courteous manner ; for example when they are talking about inconsequential information.
5. Speak loudly and clearly to patients that are hard of hearing or elderly. Also make sure there hearing aid is on when asking them questions!.
6. Wear a watch to make sure I don’t go over the time limit specified for that patient.
On Wednesday (12/05/2010) in the first week of my placement I was asked to assess and treat a 65 year old woman. This woman had come in to the Swan Districts outpatient’s physiotherapy department needing therapy for her right total knee replacement (TKR) that was performed three weeks ago on the 22/04/2010. This woman had complications after her TKR that included a clot in her left lung and DVT complications. On discharge, it was noted in her referral form, that her right quads lag was -200 and her right knee flexion was 750 . There was no other information given on her referral form.
I greeted this lady in the waiting area and asked her to come through into the treatment room, she was ambulating on two elbow crutches.
My supervisor was not going to come into the room with me but he was simply going to check with me after the assessment and treatment to see that I was on the right track.
Task
My task was to perform a subjective and objective assessment of this woman and work out an appropriate treatment plan to address any impairment’s that I might find in her assessment.
Action
I performed a subjective and objective assessment on this lady, I asked her a number of questions and tested her range of motion and strength of both her lower limbs. I found that she now had a quads lag of 300 and knee flexion of 750 . I then tailored my treatment towards increasing her range of motion for knee flexion and strengthening up her quadriceps muscles.
Result
The lady understood her programme and was happy to comply with it. The session addressed her impairments of decreased right knee flexion and decreased strength in her right leg, so it was beneficial in this way. However there were some components of my subjective assessment that needed extra work to make sure I had an accurate description of her situation.
Evaluation
I think there were some strengths in my session with this woman ; I think I performed my treatment well, and I gave her a easy exercise programme to follow at home. I think I went through the programme thoroughly with her and gave her an opportunity to ask any questions of me, making sure she understood the programme well.
I think there were some weaknesses in my session; I don’t think the subjective assessment went too well, I had to clarify some of my questions a couple of times so the patient understood what I was saying. I also forgot to ask my patient some questions that were impertinent to ask. In addition I thought that sometimes I asked questions that lead the patient to respond in a certain way; ie I influenced their answer. I think I also took a very long time with this patient; the whole session took an hour and a half.
Strategies
I worked out appropriate strategies to make sure that next time I was going to assess a patient I could perform a thorough and comprehensive subjective assessment.
1. Make sure the questions that I ask are open ended questions; where the patient can talk; giving them an opportunity to impart all their information. Also to refrain from using closed questions, where the patient only answers yes or no.
2. Make sure that my questions are not leading in anyway, that my questions do not influence my patients answer.
3. Use the prompts on the assessment sheet to make sure I don’t forget to ask any important questions.
4. Be aware when to redirect the conversation in a respectful and courteous manner ; for example when they are talking about inconsequential information.
5. Speak loudly and clearly to patients that are hard of hearing or elderly. Also make sure there hearing aid is on when asking them questions!.
6. Wear a watch to make sure I don’t go over the time limit specified for that patient.
Sunday, May 9, 2010
INITIAL ENTRY- SWAN DISTRICTS
I have been placed at Swan District Hospital (SDH) for my musculoskeletal placement. I go all week from 9am-4pm on Monday and then 8am-4pm on Tuesday to Friday. I have been placed in the outpatients sector; this is very different to all my other placements which have been inpatient settings. I suspect I will see a whole range of patients who are in the acute stage right through to end stage rehabilitation.
I’m hoping to become a Musculoskeletal physiotherapist so I am really looking forward to this rotation.
I have been told by other students to expect to see post-operative patients (total hip and knee replacements and anterior cruciate ligament and rotator cuff reconstructions) and also a lot of post-fracture patients.
If I only see these types of patients, I will be a bit disappointed; the reason for this being that these types of patients will already have a diagnosis of their condition. This means that I will not be able to get practice with diagnosing a person’s problem (from their subjective and objective examination) which is done regularly in a private practice setting.
On this placement I’m hoping to see some patients with some form of neurological involvement. I think neural compromise would be very interesting to see and pick up in a patient. I hope I get some exposure to these types of patients as we have not covered a lot of ground at uni with treating patients with neurological involvement.
I’m hoping to perform my subjective and objective assessment fluently, comprehensively and thoroughly. I think there are a lot more portions to a assessment in the musculoskeletal sector in physiotherapy compared to the other sections ( such as cardio respiratory or neuro) and I’m hoping I don’t forget all my special tests we practiced in second and third years!.
I have been told that at Swan Districts Hospital you often are able to witness surgical procedures; I really hope I can witness one of those at sometime during my placement. I think witnessing something like that will broaden my understanding and appreciation of drastic operations such as total hip and knee replacements.
Im a bit concerned about the distance I have to travel to get to SDH. SDH is a long way away from me and I need to travel along the Reid highway in peak hour traffic to get to the hospital. I will have to leave a hour and a half earlier to get there in time to start the day. I think I will need early nights!.
I’m hoping to become a Musculoskeletal physiotherapist so I am really looking forward to this rotation.
I have been told by other students to expect to see post-operative patients (total hip and knee replacements and anterior cruciate ligament and rotator cuff reconstructions) and also a lot of post-fracture patients.
If I only see these types of patients, I will be a bit disappointed; the reason for this being that these types of patients will already have a diagnosis of their condition. This means that I will not be able to get practice with diagnosing a person’s problem (from their subjective and objective examination) which is done regularly in a private practice setting.
On this placement I’m hoping to see some patients with some form of neurological involvement. I think neural compromise would be very interesting to see and pick up in a patient. I hope I get some exposure to these types of patients as we have not covered a lot of ground at uni with treating patients with neurological involvement.
I’m hoping to perform my subjective and objective assessment fluently, comprehensively and thoroughly. I think there are a lot more portions to a assessment in the musculoskeletal sector in physiotherapy compared to the other sections ( such as cardio respiratory or neuro) and I’m hoping I don’t forget all my special tests we practiced in second and third years!.
I have been told that at Swan Districts Hospital you often are able to witness surgical procedures; I really hope I can witness one of those at sometime during my placement. I think witnessing something like that will broaden my understanding and appreciation of drastic operations such as total hip and knee replacements.
Im a bit concerned about the distance I have to travel to get to SDH. SDH is a long way away from me and I need to travel along the Reid highway in peak hour traffic to get to the hospital. I will have to leave a hour and a half earlier to get there in time to start the day. I think I will need early nights!.
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