WEEK 3

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.

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.

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!.

FINAL ENTRY

I found this placement quiet challenging. I did enjoy the cardio-respiratory side to this placement, and I found that the practical side of cardio-respiratory is very similar to the theoretical side that we learn in university.
I found I became very exhausted over this placement, I found I got very little sleep trying to get too and from Fremantle Hospital in peak hour traffic and then coming home in the same traffic, I was spending over 2 hours a day driving. I did have my own caseload in this placement on some days, other days I would work with a partner, this was advantageous because; with some patients who had a number of “attachments” it was essential to have a second pair of hands.
I ended up working in the surgical ward for over 3 weeks and then I was able to work on the general medical ward for the last 2 weeks. This was really good because I was able to see a range of different chest presentations. I got to treat patients who were at the end stage COPD, and others with chronic bronchitis on the general medical ward, but on the surgical ward I was able to get exposure to all the chest complications that can be resultant from surgery and in addition to that all the attachments a patient can have . I entered ICU about 3 times during my placement. It was great to be able to have that exposure, because the runnings of ICU differed greatly from the running’s over the whole hospital.
I got to see one pulmonary rehabilitation class at the end of my placement. It was good to get exposure to this class, I wasn’t asked to run the class but it was good to observe how they conducted the session.
I think I learnt a lot about subjective questioning in this placement, I think I improved my auscultation skills greatly as well as my reading of chest X-rays, I learnt how to refine my communication skills with patients and how to articulate myself more precisely.

WEEK 5-ENTRY 3

Situation
In the fifth week of my placement I was asked to give chest care advice to a 66 year old man who was 1 day post-op for a laparotomy ( upper abdominal surgery) to remove a section of his bowel that was cancerous . This man had a past medical history of type 2 diabetes melinitus, hypertension, peripheral vascular disease and a MI (2008). He lives with his wife, they have no stairs in their home and they receive no services. This man usually ambulates unaided and can walk up to 1 kilometre without needing a rest. This man was resting in bed but was in a lot of pain, scoring 7/10 at rest.
Task
I was asked to go treat this man who had undergone a laparotomy 1 day ago.
Action
I performed a subjective interview with this man and I found out a lot of the information mentioned above, I also found out that he was in a lot of pain. I then performed a objective examination and found his problem list to be 1) pain 2) decreased lung volumes 3) impaired gass exchange 4 ) reduced exercise tolerance.
I then tried to address his problems;

Intervention
This is what I did with this man:
- Taught supported cough with a rolled up towel.
- Educated him on sitting upright in bed.
- Active cycle of breathing techniques x 3 repetitions ( 5x thoracic expansion exercises)
- Gave him circulation exercises for his lower limbs (x 10 rep)
- Gave him post-operation chest education.
Result
I gave this man an effective way to clear his chest (by coughing) without increasing his levels of pain in his abdomen. And I optimised his lung function through positioning and deep breathing exercises, I also educated him on the effects of surgery on the chest.

Evaluation
I think the session went pretty averagely. I ended up saying all that I needed to tell the patient about his chest care; however I think there were a lot of improvements I could have made to the session.
The strengths in the session were; that I related well to the patient. I gave the patient all the appropriate advice they needed for correct physiotherapy chest care and he performed his exercises well under my direction.
However, there were a few weaknesses with my session as well, the structure of my advice was a bit haphazard, it needed to be more organised. At one point my patient became confused, and I needed to clarify a few of the things I was saying.
Another weakness that my supervisor pointed out; was the fact that I got a patient to do a activity and then explained the benefits after they did it, my supervisor said that it would be better to explain the benefits of something before you get a patient to perform the task. Lastly I should have made sure my patient had adequate pain relief ( checked if the nurse could give him some more pain relief) before talking to him, as his extremely high levels of pain could have affected his understanding of what I was explaining to him.

Strategies
I thought up a few good strategies that would help me when I have to perform post operational education on patients
- don’t use jargon, or medical terminology when explaining things to patients
- have a well thought out ‘post-operation’ spiel to tell patients who have undergone abdominal surgery, so they know the risks associated with surgery and the implications it has on the chest.
- Tell the patients the benefits of doing an exercise/treatment before actually getting them to perform it, as this well increase their motivation to perform a treatment and they will know the purpose of the treatment.
- Ask the patient if they have understood what your explaining to them
- Ask the patient if they have anymore questions associated with your treatment.

WEEK 3

Situation
In the third week of my placement I was asked by my supervisor to assess and treat a 75 year old man, who had been taken in to Fremantle emergency department via ambulance.
The man had come in with respiratory arrest; he had had increased shortness of breath over the last two weeks and had gone to see a general practitioner three days ago. The man had a past medical history of ‘asthma’ (which was likely to be undiagnosed COPD) , high cholesterol, hypertension, peripheral vascular disease and a laperotomy in 2007 for a bowel obstruction. He was also very obese. This man also had a 40 year smoking history.
The gentleman lived alone and had no services helping him out, he used to walk approximately 500m in a day, without the help of any aids.
This man was admitted to Fremantle hospital on the 06/04/10 and I was asked to assess and treat him on the 07/04/10.

Task
I was asked to assess and treat this patient, trying to help with his respiratory problems, so he could return home to his previous level of function.

Action
I asked this patient a few questions regarding his shortness of breath, his flem production, dizziness and nausea, his pain levels and his home environment. I then performed an objective assessment, listening to his lungs with a stethoscope, listening to his cough, and feeling his chest expansion.
I then treated this patient. I gave his positions to ease his shortness of breath. I gave him techniques to clear flem/sputum from his lungs and I educated him about staying upright etc. I also gave him exercises to do hourly.

Result
The treatment session went well, the patient improved his shortness of breath and he also cleared out a fair bit of sputum/flem, the objective assessment also went well. However the subjective assessment didn’t go too well, it took along time and I had to keep rewording my questions so the patient understood.

Evaluation
I thought the session had both strengths and weaknesses in it. I thought my strengths were: 1) the treatment session addressed the patient’s main problems 2) I built a rapport very easily with the patient 3) I kept the session to a 30 minute time frame.
I thought I had some weaknesses in my session as well, I think my subjective assessment went poorly. I think I got nervous while asking the patient questions. I forgot to ask some pertinent questions and didn’t ask enough detail in other questions. In addition I wasn’t clear with some of my questions and I found I had to clarify a couple of times what I was asking the patient.

Strategies
I came up with a number of strategies to help improve my subjective assessment questioning. They were:
1) slow done, and take time asking questions
2) Use a notebook with questions written on it to help jog my memory so I don’t forget some pertinent questions when doing a subjective assessment.
3) Keep a neutral tone when talking to patients ( make sure it doesn’t sound condescending etc.)
4) Speak in a loud voice to make sure I am heard clearly and accurately. 5) Plan out what I want to ask a patient before entering the room so I know what questions are relevant to this patient before I even begin the subjective assessment

WEEK 1- FIRST ENTRY

Situation
On the third day of my placement ( 24/03/2010) my supervisor asked me to treat a 54 year old lady. This woman was 1 day post-operation from a laprascopy (a operation involving a large incision to the abdomen) that was performed to remove half of her colon (hemicolectomy) . Her past medical history included hypertension, hypercholesterolemia, and type 2 diabetes melinitus, she was also very obese.
This lady had only recently immigrated to Australia 2 years ago and she was of Polish decent. She could not speak English very well and her understanding of the language was very limited as well. This lady lived alone but was regularly visited by both her sons.

Task
My task was to treat this lady. This woman did not actually have any current problems with her chest, but I was treating her as more of a preventative measure to stop her contracting any post-operative complications such as chest infections or circulatory problems. I needed to asses her lungs and then treat any problems I saw.

Action
Firstly I assessed this lady. I auscultated her lungs and heard some crackling in both the lungs bi-basally. This could have indicated microatelactisis, which is very common after a long anaesthetic. I felt her chest expansion, which was good both sides and listened to her cough, which was weak, dry, non-productive and ineffective. I needed to improve her cough and possibly reverse her microatelactisis.
As a treatment I got her to take some deep breaths with an inspiratory hold at the end of them. I also showed her how to perform a supported cough (with a rolled up towel pressed against her incision site) to protect her incision site on her abdomen. As she was not feeling well enough to get out of bed I positioned her in high sitting in the bed and them attempted to educate her about the procedure, how important it was for her to keep taking deep breaths and that if she needed to cough up any mucous or flem she must attempt to cough while supporting her incision site.

Result
This woman then had post operative exercises that would help in preventing any lung or circularity problems that are sometimes associated with people who have operations that involve incisions on their abdomen and consequently long anasthetics.

Evaluation
I don’t think the treatment session was that successful. I did have some strengths with the treatment, they were:
1) I targeted the negative effects of anaesthetic on this woman’s lungs and I did prescribe her the appropriate exercises for preventing post operative complications to her lungs and circulation.
But I think I had a few more weaknesses, they were:
1) The fact that there was a lot of miscommunication occurring during the assessment and treatment session. I found it difficult to inform this lady that I was trying to prevent her from getting a chest infection. At one stage she thought she already had a chest infection and was getting quiet upset about it all.
2) I think I should have got this lady sitting on the edge of the bed, which would use more of her own muscle strength instead of letting her just sit up in bed. Sitting her out of bed would have been more beneficial in her rehabilitation from her operation (on the muscles of her abdomen).
3) I think I should have given her more exercises to target her circulation.

Strategies
My supervisor and I worked out a couple of strategies to help with communication when I come across this type of patient again:
1) Using simple short/direct words for a patient with a language barrier as well as trying to avoid complicated or long sentences. In this particular case instead of going through the whole spiel about post operative complications I should have told her the main points in a simplified way.
2) Drawing or writing down the exercises I give her so as to make sure she understands what I want her to do.
3) Using physical demonstrations to aid in teaching exercises
4) Getting the patient to repeat what you have asked them to do. I should say phrases like “So what are you going to do every hour?”. Their answer to this question would assure me of their understanding of the exercises that I have prescribed them to do.
5) Lastly get an interpreter to help out with communication.