I think most of the information I received about the placement was accurate regarding the structure, expectations and level of Independence so I was well prepared in that aspect. It was good that we started seeing patients on our own straight away as it pushed me to develop a lot faster, increased my confidence sooner and developed my communication, assessment and treatment skills more rapidly too. It also highlighted areas that I needed to work at home.
The expectations were made clear by the supervisor regarding a sound knowledge of anatomy, assessment and treatment techniques. They also encouraged me to clinically reason with each patient and to also keep an open mind to new concepts and ideas.
Being able to see our patients referral the previous day was a big help for me as it allowed me to brush up on that area and any techniques I was uncertain with. This then allowed me to be more confident when discussing the patient in the morning tutorials and later when I was actually seeing the patient.
My concern prior to the placement (re not knowing what exactly was wrong with the patient) was eliminated early on as our supervisor explained that you don't always need a diagnosis to be able to treat the patient well and see results. I then learned to use the following tips; 1) the simplest answer as to the reason of someones pain is often the right one 2) treat what you see 3) work from the outside in. These three guidelines helped me to simplify the problem and treat the most necessary things.
Saturday, July 24, 2010
Friday, July 23, 2010
Week Five Entry- Professional Behaviour/Communication
Situation:
49yr old female was referred to physio for low back pain. She presented to clinic with a very antalgic gait and posture. After the subjective history, it became clear that this lady had complex psychosocial issues going on. Her LBP started just after the death of her husband whom she had been a carer for the previous 4yrs. His care involved lots of heavy lifting and she reported having to lift him off the floor numerous times. She also has two sons. She has a 19yr old who has been diagnosed with mild autism. She also has a 13yr old who she suspects as ADHD and he is currently undergoing testing. The 13yr old has recently been skipping school. The patient has been contacted by the school and they have threatened to take her to court unless his attendance improves. The patient is also illiterate and has received no formal education (both her parents died when she was 2). She is incontinent of urine (urgency, stress and urge incontinence), has regular falls due to her knees giving way and she cannot get up off the floor so has to call for someone to help. She has recently noticed an increase in memory loss, she does not drive and she has no family in Australia.
Task:To provide an assessment and treat this patient, taking into consideration her psychosocial issues and her culture.
Action:
After the subjective assessment I continued with the objective, firstly looking at her posture. During the assessment I was able to place my hands on her with no complaint of pain and place a reasonable amount of pressure while palpating her thoracic and lumbar spine. I then went onto active movements. Every direction caused her pain and she was gasping, wincing, and jerking out of every movement. There was no difference in the type or intensity of the pain between the different movements. To have a closer look at her lower back I asked if she would move over to the plinth. She was then able to bend forward to pick up her bag from the floor and move it without any complaint of pain. She reported she could not lie prone so I did the assessment with the patient in sitting. This time when I placed my hand on her she again displayed non-organic pain behaviours and was wincing, gasping and jerking with only light touch. As I was not able to do any further testing I used this time to consult with my supervisor. He also agreed that this patient had huge psychological component contributing to her pain and that it too would need to be addressed. He also agreed that she should not be transferred to another student as this type of patient would benefit from consistency and would probably feel more comfortable with a senior staff member.
Result:
I returned to the patient and provided her with some reassurance and education about her back pain and the process involved to try and decrease the intensity of the pain. As no “hands on” treatment was appropriate in that session, I provided her with education regarding the use of heat over the area to help relax the muscles and reduce pain. I also explained to her that movement is good for the back and I encouraged her to increase the amount of movement she was doing with general, gentle exercises and stretches.
After this explanation the patient showed good understanding and her mood also seemed to improve. Her pain postures and abnormal gait pattern also was less obvious.
Evaluation:
I think I handled this complex patient well. I listened to what the patient had to say and documented important things but ensured I did not dramatise/catastrophise as this would only heighten the patients’ perception of pain. I maintained a holistic approach by discussing the involvement of social work/psychology with my supervisor. I also was culturally sensitive to the patient.
Strategies:
To continue managing complex patients well, I think I need to be confident in the information and education I am providing them. Also remembering to avoid over complicating the situation and initially just providing education and treating what I see in front of me.
49yr old female was referred to physio for low back pain. She presented to clinic with a very antalgic gait and posture. After the subjective history, it became clear that this lady had complex psychosocial issues going on. Her LBP started just after the death of her husband whom she had been a carer for the previous 4yrs. His care involved lots of heavy lifting and she reported having to lift him off the floor numerous times. She also has two sons. She has a 19yr old who has been diagnosed with mild autism. She also has a 13yr old who she suspects as ADHD and he is currently undergoing testing. The 13yr old has recently been skipping school. The patient has been contacted by the school and they have threatened to take her to court unless his attendance improves. The patient is also illiterate and has received no formal education (both her parents died when she was 2). She is incontinent of urine (urgency, stress and urge incontinence), has regular falls due to her knees giving way and she cannot get up off the floor so has to call for someone to help. She has recently noticed an increase in memory loss, she does not drive and she has no family in Australia.
Task:To provide an assessment and treat this patient, taking into consideration her psychosocial issues and her culture.
Action:
After the subjective assessment I continued with the objective, firstly looking at her posture. During the assessment I was able to place my hands on her with no complaint of pain and place a reasonable amount of pressure while palpating her thoracic and lumbar spine. I then went onto active movements. Every direction caused her pain and she was gasping, wincing, and jerking out of every movement. There was no difference in the type or intensity of the pain between the different movements. To have a closer look at her lower back I asked if she would move over to the plinth. She was then able to bend forward to pick up her bag from the floor and move it without any complaint of pain. She reported she could not lie prone so I did the assessment with the patient in sitting. This time when I placed my hand on her she again displayed non-organic pain behaviours and was wincing, gasping and jerking with only light touch. As I was not able to do any further testing I used this time to consult with my supervisor. He also agreed that this patient had huge psychological component contributing to her pain and that it too would need to be addressed. He also agreed that she should not be transferred to another student as this type of patient would benefit from consistency and would probably feel more comfortable with a senior staff member.
Result:
I returned to the patient and provided her with some reassurance and education about her back pain and the process involved to try and decrease the intensity of the pain. As no “hands on” treatment was appropriate in that session, I provided her with education regarding the use of heat over the area to help relax the muscles and reduce pain. I also explained to her that movement is good for the back and I encouraged her to increase the amount of movement she was doing with general, gentle exercises and stretches.
After this explanation the patient showed good understanding and her mood also seemed to improve. Her pain postures and abnormal gait pattern also was less obvious.
Evaluation:
I think I handled this complex patient well. I listened to what the patient had to say and documented important things but ensured I did not dramatise/catastrophise as this would only heighten the patients’ perception of pain. I maintained a holistic approach by discussing the involvement of social work/psychology with my supervisor. I also was culturally sensitive to the patient.
Strategies:
To continue managing complex patients well, I think I need to be confident in the information and education I am providing them. Also remembering to avoid over complicating the situation and initially just providing education and treating what I see in front of me.
Sunday, July 4, 2010
Week Three Entry- Intervention
Situation:
79 year old male presented with right shoulder pain which was anterior and lateral in its distribution. Onset was insidious starting approximately 6 weeks ago with no identified cause. Aggravating factors included his right arm resting on an armchair/table and also lying on his left side at night. The problem was mildly irritable. On objective examination, the patient had full range of motion in all directions with no pain. Speed's test and Neer's test provoked a small amount of pain. Palpation of the long head of biceps and the insertion of deltoid was tender and reproduced his pain.
Task:
To provide the patient with appropriate information and education regarding his condition and ways he can manage it at home. Also to provide effective, hands on treatment during this session with the patient.
Action:
I provided the patient with education regarding the possible inflammatory process going on. I also gave him a home exercise program consisting of the use of heat/ice as well as some general range of motion and postural exercises. I also treated his tender areas with ultrasound with settings of continuous, 1MHz, 6mins, 0.5-1.0Wcm.
79 year old male presented with right shoulder pain which was anterior and lateral in its distribution. Onset was insidious starting approximately 6 weeks ago with no identified cause. Aggravating factors included his right arm resting on an armchair/table and also lying on his left side at night. The problem was mildly irritable. On objective examination, the patient had full range of motion in all directions with no pain. Speed's test and Neer's test provoked a small amount of pain. Palpation of the long head of biceps and the insertion of deltoid was tender and reproduced his pain.
Task:
To provide the patient with appropriate information and education regarding his condition and ways he can manage it at home. Also to provide effective, hands on treatment during this session with the patient.
Action:
I provided the patient with education regarding the possible inflammatory process going on. I also gave him a home exercise program consisting of the use of heat/ice as well as some general range of motion and postural exercises. I also treated his tender areas with ultrasound with settings of continuous, 1MHz, 6mins, 0.5-1.0Wcm.
Friday, June 25, 2010
Week One Entry- Assessment
Situation:
I was transferred a patient from another student to continue the care of an 82 year old male who recently had a fall. He had slipped and fallen directly onto his right knee. On initial assessment by the previous student, he had 0-8/10 intermittent pain at the right posterior knee and 0-6/10 intermittent pain at the anterior knee. Aggravating factors included getting into and out of the car, getting out of bed, prolonged sitting >15 mins and putting on shoes. Easing factors included walking, movement of the knee, lying down and self massage. It was also observed that at his last visit he had bilateral swelling at both of his ankles.
Task:
To continue to provide a thorough and holistic assessment of this patient and to then provide appropriate treatment for what his current presentation is.
Action:
After subjective questioning, it became clear that the patient thought his overall pain levels had decreased. He had been compliant with his home exercise program and also noticed improvements in his knee flexion range. The patient also raised some concern about the swelling in his lower limbs. On observation, it was evident that his entire lower limb (up to his knee) was swollen. The patient described his leg as painful, tight and heavy. To look at the skin was very shiny and tight and on palpation it was slightly warmer than the left leg and there was obvious pitting oedema. I then assessed pain levels of calf palpation as well as passive dorsiflexion. After a few other muscle length/strength tests I went to consult with my supervisor of my findings.
Result:
Due to my objective assessment, I was able to identify to my supervisor potential red flags this patient might have. First of all I thought about some kind of inflammation (hot and swollen areas) process occuring. I then thought about the possibility of a DVT. This was a potential cause but the testing I had already done had reduced the likelihood of that ie: no tenderness of gastroc/soleus and no pain on passive dorsiflexion (therefore -ve Homan's sign). Cellulitis was another possible differential diagnosis. My supervisor decided to come and have a look with me. To help manage the swelling I suggested using some tubigrip which my supervisor agreed that it could be of help. He also recommended that the patient go and see his doctor about this sudden increase in swelling. I then also suggested that I could take circumferential measurements of the foot, ankle and calf as an objective measure to use as a comparison when the patient returned in a weeks time. My supervisor also agreed that the measures would be beneficial.
Evaluation:
I think I did well in this assessment as I listened to the patients current concerns and then examined the area very closely. Also knowing the signs and sypmtoms of potentially more serious problems allowed me to do a thorough examination of the area. This previous knowledge of the signs and symptoms of DVT and the tests to assess (Homan's sign) came mainly from my previous cardio and neuro placements. Also, knowing how to do sa tandardised measure of the calf circumference was from doing lymphoedema measurements at my women's health placement. I think this really shows that you can't divide physio into certain categories (cardio, neuro, WH etc) as there will always be a case where crossover occurs and you will need to know various assessments from all the specialties.
Strategies:
From this I have learned that you aren't providing the best care for your patients if you have "tunnel vision" and are too musculo focussed. To try and avoid this happening in the future I will endevour to keep an open mind when doing assessments and be sure to integrate all aspects of physio in my assessments.
I was transferred a patient from another student to continue the care of an 82 year old male who recently had a fall. He had slipped and fallen directly onto his right knee. On initial assessment by the previous student, he had 0-8/10 intermittent pain at the right posterior knee and 0-6/10 intermittent pain at the anterior knee. Aggravating factors included getting into and out of the car, getting out of bed, prolonged sitting >15 mins and putting on shoes. Easing factors included walking, movement of the knee, lying down and self massage. It was also observed that at his last visit he had bilateral swelling at both of his ankles.
Task:
To continue to provide a thorough and holistic assessment of this patient and to then provide appropriate treatment for what his current presentation is.
Action:
After subjective questioning, it became clear that the patient thought his overall pain levels had decreased. He had been compliant with his home exercise program and also noticed improvements in his knee flexion range. The patient also raised some concern about the swelling in his lower limbs. On observation, it was evident that his entire lower limb (up to his knee) was swollen. The patient described his leg as painful, tight and heavy. To look at the skin was very shiny and tight and on palpation it was slightly warmer than the left leg and there was obvious pitting oedema. I then assessed pain levels of calf palpation as well as passive dorsiflexion. After a few other muscle length/strength tests I went to consult with my supervisor of my findings.
Result:
Due to my objective assessment, I was able to identify to my supervisor potential red flags this patient might have. First of all I thought about some kind of inflammation (hot and swollen areas) process occuring. I then thought about the possibility of a DVT. This was a potential cause but the testing I had already done had reduced the likelihood of that ie: no tenderness of gastroc/soleus and no pain on passive dorsiflexion (therefore -ve Homan's sign). Cellulitis was another possible differential diagnosis. My supervisor decided to come and have a look with me. To help manage the swelling I suggested using some tubigrip which my supervisor agreed that it could be of help. He also recommended that the patient go and see his doctor about this sudden increase in swelling. I then also suggested that I could take circumferential measurements of the foot, ankle and calf as an objective measure to use as a comparison when the patient returned in a weeks time. My supervisor also agreed that the measures would be beneficial.
Evaluation:
I think I did well in this assessment as I listened to the patients current concerns and then examined the area very closely. Also knowing the signs and sypmtoms of potentially more serious problems allowed me to do a thorough examination of the area. This previous knowledge of the signs and symptoms of DVT and the tests to assess (Homan's sign) came mainly from my previous cardio and neuro placements. Also, knowing how to do sa tandardised measure of the calf circumference was from doing lymphoedema measurements at my women's health placement. I think this really shows that you can't divide physio into certain categories (cardio, neuro, WH etc) as there will always be a case where crossover occurs and you will need to know various assessments from all the specialties.
Strategies:
From this I have learned that you aren't providing the best care for your patients if you have "tunnel vision" and are too musculo focussed. To try and avoid this happening in the future I will endevour to keep an open mind when doing assessments and be sure to integrate all aspects of physio in my assessments.
Sunday, June 20, 2010
Initial Entry- 4th Placement 2010
I'm quite excited about starting this placement tomorrow. I'm not sure if it's because of the musculo-skeletal outpatients facility or the fact that it is the start of our last rotation for the year!
I think the structure of this placement will be slightly different to my previous 3, in that there is much more independence expected from students from day 1. After speaking to other students and the facility supervisor, I know I will be seeing patients on my own tomorrow morning, whereas in all my other placements the first day was more orientation and we may have sat in on a treatment session to observe. This is a little bit daunting but I feel as though my previous placements have helped me build confidence in communicating with patients and other staff. So I don't think I'm as nervous now as what I might have been if this was my first rotation back in February.
From the information package that this facility had sent out, it appears they have set expectations of students to be well prepared for this placement in the way of theory, assessment and treatment techniques. I think this is an essential request as it will also facilitate us to get the most out of the placement and enable us to progress beyond the basics which we have learnt at university. I'm sure it will become obvious in the first few days if I have met the expectation and prepared well enough!
Another advantage of this placement (and all outpatient departments) is that I will know what patients I am seeing the day before their appointment. I think this will suit my style of learning really well because I can go home the night before and cover anything may be unsure of and I can also plan various possible treatments. This is just another aspect of being prepared which I feel will help give me more confidence when I'm actually with the patient.
If I had to pick out a concern I have, it would probably be coming out of a subjective history and not knowing what is happening with the patient. What reassures this concern is that the facility has already said that there may be some conditions that pop up which may be new to us and we won't know the answers. It's in that situation where the senior physio will be able to provide that extra bit of guidance and assistance in helping me work out the problems.
Overall, I'm ready excited to get this placement started... the countdown has begun!
I think the structure of this placement will be slightly different to my previous 3, in that there is much more independence expected from students from day 1. After speaking to other students and the facility supervisor, I know I will be seeing patients on my own tomorrow morning, whereas in all my other placements the first day was more orientation and we may have sat in on a treatment session to observe. This is a little bit daunting but I feel as though my previous placements have helped me build confidence in communicating with patients and other staff. So I don't think I'm as nervous now as what I might have been if this was my first rotation back in February.
From the information package that this facility had sent out, it appears they have set expectations of students to be well prepared for this placement in the way of theory, assessment and treatment techniques. I think this is an essential request as it will also facilitate us to get the most out of the placement and enable us to progress beyond the basics which we have learnt at university. I'm sure it will become obvious in the first few days if I have met the expectation and prepared well enough!
Another advantage of this placement (and all outpatient departments) is that I will know what patients I am seeing the day before their appointment. I think this will suit my style of learning really well because I can go home the night before and cover anything may be unsure of and I can also plan various possible treatments. This is just another aspect of being prepared which I feel will help give me more confidence when I'm actually with the patient.
If I had to pick out a concern I have, it would probably be coming out of a subjective history and not knowing what is happening with the patient. What reassures this concern is that the facility has already said that there may be some conditions that pop up which may be new to us and we won't know the answers. It's in that situation where the senior physio will be able to provide that extra bit of guidance and assistance in helping me work out the problems.
Overall, I'm ready excited to get this placement started... the countdown has begun!
Sunday, June 13, 2010
Final Entry- 3rd Placement
This placement definitely lived up to my expectations. I was exposed to a whole variety of things which has allowed me to get a good grasp of all the things women's health incorporates as well as some aspects of what the paediatric physios do too.
The lecture material from uni was a good basis to start from, but as I expected most of the information was taught at KEMH and picked up along the way. I got so much out of the tutorials and really valued the time that I had with the tutors. I was especially grateful for the time I spent with the uro-gynae consultants. I sat in on their appointments in the clinic as well as watching multiple surgeries and also observing urodynamics. Having this extra exposure really helped me develop the bigger picture for these patients we were seeing on the ward and in outpatients.
A basic level of understanding was expected from my supervisors but it was obvious that a lot of this information was new to us. In that respect they were always willing to explain or elaborate on anything which was new to me or that I may not have fully understood.
Overall, I feel that I have learnt a lot on this placement and that this experience may have steered me in the direction of wanting to pursue a career in the women's health field!
The lecture material from uni was a good basis to start from, but as I expected most of the information was taught at KEMH and picked up along the way. I got so much out of the tutorials and really valued the time that I had with the tutors. I was especially grateful for the time I spent with the uro-gynae consultants. I sat in on their appointments in the clinic as well as watching multiple surgeries and also observing urodynamics. Having this extra exposure really helped me develop the bigger picture for these patients we were seeing on the ward and in outpatients.
A basic level of understanding was expected from my supervisors but it was obvious that a lot of this information was new to us. In that respect they were always willing to explain or elaborate on anything which was new to me or that I may not have fully understood.
Overall, I feel that I have learnt a lot on this placement and that this experience may have steered me in the direction of wanting to pursue a career in the women's health field!
Week 5 Entry- Professional Behaviour
Situation:
63 year old female patient was booked to undergo urodynamic tests. Her history included urgency, urge incontinence, recurrent UTI's and dysuria. This patient was very anxious about having the tests done and also was very emotional about her current symptoms. She was clearly distressed about the whole situation and she was overwhelmed with the number/size of machines in the room as well as the number of people in the room. Throughout the process (catheters being inserted, bladder inflated) she became more and more emotional and distressed. She also found it extremely difficult to hold in large volumes during the testing so leakage was also occurring.
Task:
To maintain professional behaviour during the testing while also demonstrating sympathy and understanding for the patient.
Action:
After the testing was complete, I was asked to escort the patient to the uro-gynae clinic where she would wait for the consultant to discuss with her what the test results showed. The patient was still quite emotional at this time so I tried to explain some of the mechanisms behind what was actually causing her bladder to "misbehave". This gave the patient a better understanding of the reasons of why she was experiencing her symptoms. I tried to reassure her in that it is quite a common problem amongst older females and that many people are going through the same thing she is. The last thing I talked about before the consultant arrived was some simple strategies (bladder calming techniques) which she could use to help control her symptoms and hopefully avoid any accidents occurring in public places.
Results:
I think that I was able to use my position as a student to show this patient extra sympathy and understanding which helped her calm down. Once she had settled and was telling me more information I was also able to provide her with some education about her problems which she didn't seem to have received previously. She seemed very grateful for the time I had spent with her and the information I had provided.
Evaluation:
I think that I showed a good level of professionalism throughout the situation as well as demonstrating good communication skills in dealing with this complex patient. I was able to sympathise with her, which aided in calming her down, which allowed her to take in some extra information which could potentially improve her symptoms in the community.
Strategies:
To improve in the future, I could possibly be more specific about the facts related to the situation ie have a better idea of the proportion of women this can affect, the percentage of woman whose symptoms improve etc. This would just provide a little bit more reassurance and possibly some hope for the patient in that many people do improve and they too can improve and live a normal life.
63 year old female patient was booked to undergo urodynamic tests. Her history included urgency, urge incontinence, recurrent UTI's and dysuria. This patient was very anxious about having the tests done and also was very emotional about her current symptoms. She was clearly distressed about the whole situation and she was overwhelmed with the number/size of machines in the room as well as the number of people in the room. Throughout the process (catheters being inserted, bladder inflated) she became more and more emotional and distressed. She also found it extremely difficult to hold in large volumes during the testing so leakage was also occurring.
Task:
To maintain professional behaviour during the testing while also demonstrating sympathy and understanding for the patient.
Action:
After the testing was complete, I was asked to escort the patient to the uro-gynae clinic where she would wait for the consultant to discuss with her what the test results showed. The patient was still quite emotional at this time so I tried to explain some of the mechanisms behind what was actually causing her bladder to "misbehave". This gave the patient a better understanding of the reasons of why she was experiencing her symptoms. I tried to reassure her in that it is quite a common problem amongst older females and that many people are going through the same thing she is. The last thing I talked about before the consultant arrived was some simple strategies (bladder calming techniques) which she could use to help control her symptoms and hopefully avoid any accidents occurring in public places.
Results:
I think that I was able to use my position as a student to show this patient extra sympathy and understanding which helped her calm down. Once she had settled and was telling me more information I was also able to provide her with some education about her problems which she didn't seem to have received previously. She seemed very grateful for the time I had spent with her and the information I had provided.
Evaluation:
I think that I showed a good level of professionalism throughout the situation as well as demonstrating good communication skills in dealing with this complex patient. I was able to sympathise with her, which aided in calming her down, which allowed her to take in some extra information which could potentially improve her symptoms in the community.
Strategies:
To improve in the future, I could possibly be more specific about the facts related to the situation ie have a better idea of the proportion of women this can affect, the percentage of woman whose symptoms improve etc. This would just provide a little bit more reassurance and possibly some hope for the patient in that many people do improve and they too can improve and live a normal life.
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