STARES 2

SITUATION

A middle aged male artist presented to the physiotherapy clinic with left hip pain being his main complaint. On subjective examination I was able to uncover that he had recently sprained his right ankle and consequently ceased his normal activity for a period of 3 months. After his 3-month break he had rejoined martial arts class on a Wednesday afternoon. He found this activity to be aggravating, particularly falling to the ground onto his hip and the jarring of landing was most painful. The morning was stiff and sore with slight improvement after some movement, though excessive exercise also aggravated it. He also reported a prior diagnosis of arthritis in his hips, which he is currently taking medication for. When asked further about any other pains, he reported symptoms in his shoulders bilaterally that became most prevalent with driving. On a long drive the shoulder pain progressed to pins and needles in his hands, in the median nerve distribution and shaking his hands alleviated the pins and needles temporarily, though not the shoulder pain. He had no troubles with painting. He no longer had pain in his ankle. From this subjective examination, the relevant objective examinations were carried out on the hip, shoulder and wrist joints. It was found that the left hip had significantly reduced ROM, especially into flexion and was painful on Quadrant and Faber’s test. On muscle power testing it was found that he had mildly reduced EHL power on the left indicating an L5/S1 nerve root issue. The shoulders both demonstrated positive impingement signs, particularly of supraspinatis as well as a lack of correct scapular stabilisation and posture. Finally from the subjective and objective examination of the wrists, he was found to be positive for carpal tunnel syndrome.

TASK

In this clinical situation I was to undertake this patients full initial examination and treatment independently with background supervision. This also included writing a letter back to the referring GP explaining my findings, treatment and recommendations.

ACTION

On subjective examination I proceeded to thoroughly investigate not only the referring and presenting complaint but also all other pain experiences and retrieve all relevant information to guide my objective examination. From this I developed theories on each of the pains and their source of symptoms, which I would confirm or negate through my objective. I undertook the relevant tests of the hip, shoulders and wrists with occasional hints and suggestions from my supervisor. From this I made an clinically reasoned diagnosis of what was causing each pain experience; arthritis in the hip joint and tightening of the hip capsule, decreased mobility at the left L5/S1 facet joint, bilateral shoulder impingement and carpal tunnel syndrome at the wrists. I explained these to my supervisor who agreed with my findings and told me to proceed with treatment of these. My treatment incorporated mobilisation of the L5/S1 facet joint, mobilisation of the hip joint, instruction on scapula setting and posture as well as a home exercise program including hip stretches, rotator cuff stretching and strengthening and carpal tunnel stretches. After treatment, I wrote a letter to the referring GP, firstly thanking him for the referral and then proceeding to explain my findings, treatment and recommendations.

RESULT

The patient felt better and re-assured following his session. My supervisor was happy with my performance of the subjective, objective and treatment of this patient and felt confident in my clinical reasoning to identify the source of symptoms and treat accordingly.

EVALUATION:

Overall I feel I performed well in this case. I was able to thoroughly examine the patient as well as apply sound clinical reasoning to determine a diagnosis and treat this appropriately. In particular, I feel my subjective examination ability has thoroughly improved while on this placement and I am able to structure questions as well as drawing from their answers to get information that I previously would have missed. I also felt my ability to recognise possible source of symptoms from the subjective examination to narrow down my objective tests has improved and was effective and more efficient, again paying credit to my subjective examining ability. Throughout this session though, I had a few difficulties, which I would like to work on and improve my technique for future patients that may have similar presentations. Firstly, on examination of muscle power, I initially missed the EHL weakness, due to lack of experience in identifying poor quality of movement, as well as a poor technique. Secondly I lacked the endurance or strength to apply the hip mobilisations for an extended period. My supervisor then showed me a different technique that was easier, though still taxing. This is something I would like to practise and improve on. Lastly, I have had little experience in writing letters to fellow health professionals. My supervisor assisted me in writing the letter to the GP, though in future I would like to be efficient in doing this independently. My main issue with this was the language and terminology that would transfer to other health professions as well as what to include and what to leave out of the letter.

STRATEGIES:

As mentioned time and time again, having good background knowledge is the key to success in any situation. Being able to explain yourself to a fellow clinician, as well as to a patient is a skill that develops over time, though having a prior understand the concepts yourself, helps a great deal. When questioning a patient, I find asking more questions rather then less helps significantly in understanding the patient’s experience. Strategies I will employ in the future will include; practising techniques and working on techniques that I find more efficient and effective, especially for treating male patients that are a lot bigger and stronger then myself, as well as getting experience in writing letters to other health care providers and members of the community.