Frozen shoulder!

This week on my musculoskeletal placement I had a patient come in with a diagnosis of Adhesive Capsulitis (frozen shoulder), who had been referred from their GP. Upon reading the previous students notes it became clear that this patient was within the 1st/2nd stage of the pathology. Therefore I knew before even meeting the patient that they would be in a considerable amount of pain.

When I met the patient they said their pain had decreased since the last physio session, so after an brief assessment I decided to do the same treatment as the previous student. Then 3 days later the patient returned for another physio session however after the subjective assessment it was very clear that they were in more pain than the previous session. This didn’t surprise me as I knew that with this certain pathology during the inflammatory stages there is little that physio treatment could do to relieve pain. This particular day I could hardly touch the patient as everything was ‘too painful’. The patient was a little confused as to why they hadn’t improved like the last physio session.

So for the patients benefit I spent half of the treatment session explaining the stages of a frozen shoulder and how the 1st and 2nd stages were focused on relieving pain and that they would have to wait for the pathology to ‘run its course’ before they could start getting better. At the end of the session the patient seemed happy with the session and said they would continue to come to the physio treatment sessions.

FROM THIS EXPERIENCE I HAVE LEARNT THAT YOU CAN’T ASSUME THAT JUST BECAUSE THE DOCTOR HAS WRITTEN A DIAGNOSIS ON A REFERRAL FORM THAT THEY HAVE FULLY EXPLAINED THE PATHOLOGY TO THE PATIENT. PATIENTS REALLY DO APPRECIATE SOMEONE TAKING THE TIME TO EXPLAIN THEIR PATHOLOGY. NOT ONLY DOES THIS HELP COMPLIANCE WITH PHYSIOTHERAPY, BUT IT ALSO PREPARES PATIENTS WHEN A THINGS DON’T GO THE WAY THEY PLANNED.

Elbows... aagh!

A new patient I was about to see on a musculo placement had a referral letter with 'my arm hurts when I move it' as the reason for visit. This wasn't ideal in narrowing down my preparation, but I assumed it would be shoulder pain and only briefly skimmed material on the elbow. 

It turned out to be elbow pain of course.

Background - elbow pathologies we learnt about were medial/lateral epicondilagia, MCL sprain (little leagure's elbow), olecranon bursitis and radial head dislocation in children.

This patient had posterior/medial pain from 10cm above to 5cm below elbow, exacerbated by elbow extension and driving (hands on top of steering wheel). It began with ballistic extension activities (punches/push-ups) in a martial arts class.

From the beginning it wasn't fitting into the typical presentations we're familiar with from lectures. This was further confirmed with special objective tests, eg for golfer's elbow: medial epicondyle palpation, finger/wrist flexor stretch, resisted wrist flexion and pronation were all negative. 

Neural involvement was excluded by pain characteristics, neck screening, NTPTs and ulnar nerve palpation posterior to medial epicondyle.

Not knowing what to look for next I palpated the area and found a very distinct triceps 'knot' that reproduced the pain.

It turned out to be a simple triceps strain. Triceps length, pain levels, and elbow extension ROM all improved significantly with some massage and hold-relax! Also, the 'knot' nearly completely disappeared. (Other advice/HEP/education were also conducted.)

I tend to under-estimate the value of palpation as an assessment tool, probably because it seems so much easier than the specific tests we learn in labs.

This experience has re-affirmed to me its usefulness, especially in situations where the source of pain is difficult to establish.

scoliosis

Whilst conducting the objective assessment on a 15yo girl with low back pain recently, I noticed scoliotic features. For example, a thoracic curvature was palpable; in full flexion, the left rib-cage was higher than the right; the arm/waist gaps were asymetrical; one scapula protruded much more than the other and was angled differently. 

She reported never having been diagnosed with a scoliosis, or screened for them at school. She had reached menarche, but has not finished growing. 

I surmised that this factor could be contributing to her back pain, in addition to the loading/motor control disorder apparent from other objective findings.

I looked up our scoliosis notes before I saw her again, and found that after menarche, curve progression is not as much of an issue as the major growth and bony ossification have already occurred. However, as she has never had a diagnosis, and has some growth remaining... I sought confirmation from my supervisor about whether I should suggest further investigation. She agreed but emphasized that I should check for a leg length difference first.

I did this with a tape measure from ASIS to tip of lateral malleolus and found a 2cm difference. This is at the upper end of normal, however, the scoliotic signs disappeared with correction of the LLD. By placing 2cm worth of towel under one foot, the curve straightened and scapulae became symmetrical etc.

Instead of sending her to a doctor, I therefore suggested a podiatrist. I wrote a brief summary of my findings for her to give to the podiatrist as her reason for making the appointment. Hopefully an insert to make her posture symmetrical might assist, (in conjunction with our motor control interventions), to reduce her back pain.

In future if I suspect scoliosis in a patient (that is symptomatic or progressive), I will always remember to check whether LLD is a cause or contributing factor before making further recommendations.

Discussing Death

On my very last day of prac I was treating a 55 year old patient who had been diagnosed with an incurable brain tumour, the prognosis being a few months. As with all my patients I never brought up their diagnosis unless they willingly wanted to discuss it. This particular morning during my treatment session the patient began talking about their diagnosis and how it wasn’t fair as they had always been healthy, always exercised and never did anything that would be destructive to their health. As they were discussing their views on the topic with me, I just listened and didn’t comment as I wasn’t sure exactly what to say.

Until the patient asked me directly why was life so unfair, and why did she have to be the one to be diagnosed with cancer after living such a ‘healthy’ life and what was the point she may as well die now. I was extremely uncomfortable with the question and the last statement and really didn’t know exactly what to say. So instead of answering the question directly I just agreed that life wasn’t fair and that diseases like cancer can unfortunately affect anyone. I then went on the ask if she had any children to try and remind her that even though she might want to die, her family would appreciate whatever time the doctors could give their mother.

FROM THIS CONVERSATION I WAS CONFRONTED DIRECTLY REGARDING THE ISSUE OF DEATH, AND THAT FOR THIS PATIENT THERE WAS NO HOPE AND THAT THEY WOULD MOST CERTAINLY BE DYING WITHIN THE NEXT FEW MONTHS. FROM THIS EXPERIENCE AND MY WHOLE PLACEMENT, I HAVE LEARNT IT IS IMPORTANT TO LISTEN TO THE PATIENTS FEELINGS ON THE TOPIC IF THEY WANT TO DISCUSS THEM. IF LIKE MY PATIENT THEY ARE IN THE STAGE OF RESENTMENT, LET THEM VOICE THOSE OPINIONS, DON’T TRY TO CONVINCE THEM THAT THERE IS NO POINT TO BEING ANGRY AND JUST TRY TO HELP THEM UNDERSTAND THAT YOUR JOB IS TO HELP THEIR LAST FEW MONTHS BE AS COMFORTABLE AS POSSIBLE. IT IS NOT A NICE SITUATION BUT ONE THAT AS HEALTH PROFESSIONALS WE WILL FACE.

Pt with bipolar

This week a 55yo male was admitted with pneumonia to my ward after spending a week in ICU. I read the patients notes and the doctor had asked for chest physiotherapy. So with the doctor’s request in mind I went into see the patient and did a subjective and objective assessment, then took them for a walk. On returning the patient said they were tired from the session and did not want anymore chest physio that day. So I told the patient I would be back the next day to do more physio.

On returning the next morning the patient was in bed and said they were too tired and refused physio. I discussed this with my supervisor and they said next time I went into see the patient that they would come as well. The next day we both went to treat the patient however they had the same response and refused any physio. By this stage I was confused as the first day the patient had let me do some sort of physio treatment but now would not participate at all.

My supervisor suggested that I speak to the doctor and let them know that the patient was refusing physio. When I discussed the patient’s refusal to physio, the doctor said to ‘just get him up’, so I tried for a third time with no success. That afternoon the doctor came and told me they worked out the reason the patient was probably not compliant with physio was because they were in the down phase of bipolar. So bearing this in mind I understood why the patient wasn’t motivated to physio.

I HAVE LEARNT FROM THIS EXPERIENCE LIAISING WITH OTHER HEALTH PROFESSIONALS IN THIS CASE THE DOCTOR; CAN BE VERY IMPORTANT IN WORKING OUT WHAT IS CAUSING A PATIENT TO BEHAVE IN A PARTICULAR MANNER. IN THIS PARTICULAR CASE, I WILL CONTINUE TO SEE THE PATIENT EVERY MORNING AND TRY MY BEST TO MOTIVATE THEM TO JUST AMBULATE

Doing a Subjective and Objective Ax

Last week during my cardiopulmonary placement, I was reading a set of patient notes whom I had never seen before, to try and get an idea of what to expect when I went to do a subjective and objective assessment. From the notes I got that this 50yo male who had pneumonia and had been in ICU for quite a few days, they also had some mental health issues which included not being compliant with any treatment. From these notes I got the impression that this patient was going to be difficult to mobilise and treat due to the above issues.

On meeting the patient I was shocked to find he was up walking and talking, not at all what I had expected. However once I began a subjective assessment I found that his mental health issues were going to hinder my normal assessment. This occurred as I couldn’t seem to get the patient to stop talking about random topics that had nothing at all to with the questions I was asking. After 10min of trying to get a subjective assessment done, I decided to go walking with the patient to try and get some objective measures done. He was compliant with this part of the session, however when we came back to the patients room I asked if I could do some auscultation and he refused and said he had enough.

I came out of this treatment session feeling like I had hardly achieved anything, but didn’t really know what else I could have done to help this particular patient. However after speaking with my supervisor they assured me that in this particular situation I just had to record the findings that I did find out and try to get more information during the next session.

I HAVE LEARNT THAT SOMETIMES WE HAVE TO BE VERY CREATIVE WHEN TRYING TO DO A SUBJECTIVE AND OBJECTIVE ASSESSMENT ON PATIENTS. IN THIS PARTICULAR CASE I WORKED OUT THAT THE PATIENT ENJOYED WALKING, SO IN FUTURE SESSIONS I WOULD TAKE THE PATIENT WALKING AND TRY TO DO MOST OF MY SUBJECTIVE ASSESSMENT AND OBJECTIVE ASSESSMENT WHILST THEY WERE DOING SOMETHING THEY ENJOY. SOMETIMES THE FIRST SESSION WITH A PATIENT IS JUST ASSESSING THEIR PERSONALITY, SO THEN YOU CAN WORK OUT HOW BEST TO GET THE INFORMATION REQUIRED.

Vas Shmas

I recently had to asses a new musculoskeletal outpatient with shoulder pain. She had limited English and limited hearing. A simple but easy to miss measure that became ingrained on a previous gero prac is to ask whether the patient can hear more easily from one ear or another. This patient could so I repositioned the chairs so I could 'talk to her good ear', which helped immensely. During the assessment it became apparent that scoring pain  out of ten was completely unsuited to this patient. Normally if patients struggle to score their pain I ask them to choose mild, moderate or severe... and if say all three painful areas are moderate I ask them which is the worst & which is the best etc. I tried this and saw the empty look she responded with. It was obvious those terms were unfamiliar vocabulary for her. So I repeated the sentence but used 'a little bit', 'middle', and 'big' in conjunction with my hands showing increasing amounts and my face going from 'I can cope' to 'this feels like I'm giving birth'. She easily graded her pain this way. Throughout the session I consistently used these terms to avoid confusion and eventually she gave me the information without even requiring prompts. 

This has confirmed to me that watching your patients body language is essential for good communication. Had I been 'talking to my assessment sheet' I might have wasted time trying to obtain VAS scores or persistently repeating mild, moderate severe, under the assumption that her hesitancy was related to the hearing impairment. It reminded me that simple adjustments make matters a whole lot simpler.

take note... (copy & paste isn't as reliable as I thought)

For an assessment on a women's health prac it was organized that I would do a post-natal education. This involves a group of subjective questions followed by fairly standardized information about given topics. As always, the intervention is adjusted according to the individual, but it is unnecessary to read the patient notes beforehand, you unveil the essential information during the subjective.

This particular patient's answers revealed that she was likely to need intervention for perineal trauma as well as the basic PN ed. Normally before such treatment we do read patient notes, however, in my 'being assessed fluster', I thought it was one of those situations where displaying your ability to adapt your approach would be impressive. I began assessing the new problem when my supervisor politely asked for a quick chat outside... She stressed the importance of reading the history before such treatments and pointed out that the lady had drains from her caesarean. I had seen the drains bu 'fluster' took over and disregarded them. We read the notes and it turned out the drains had no bearing but of course its imperative to check when you're not sure. Having the necessary background information, I then finished the assessment and treatment.

This experience taught me to take control of the situation even if it causes inconvenience or awkwardness (such as leaving as soon as you've started). In future I will remember that small steps to ensure safety far exceed my obligation to appear professional. I will also respond more to the environment. In the aforementioned scenario, for example, I should have incorporated questions about the drains early in the subjective assessment.

take note...