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.