STARES 3

SITUATION

A 27 year old female was admitted to ward 8A under the neurology team for further investigation and treatment after presenting to the emergency department with signs and symptoms in her left lower limb including abnormal sensations, decreased active motor control, proximally greater than distally and increased tone of the classic extensor pattern. A CT scan of her brain and spine had been taken, as well as a lumbar spinal tap to determine possible causes for symptoms. All of these tests were negative.

On physio assessment it was found that she had an abnormal sensation pattern and experience in her left lower limb with a clearly defined areas. Normal awareness of sensation was graded 10/10 and using this as a reference, a specific sensory assessment was conducted to determine the most affected areas. According to the patient she had near normal awareness at her knee and on the plantar aspect of her foot with 8/10, though at her hip region and back of the thigh and calf she reported 2/10 awareness. Also noted was the description of as being “pins and needles” type sensation to all touch. In terms of active motor control there was decreased strength throughout the left lower limb in comparison to the right with impaired coordination. Tone wise, there was evident fatiguable clonus in gastroc and soleus on the left, as well as rigidity with passive movement into dorsi flexion. On standing, the left lower limb went into extension pattern with plantar flexion and inversion of the foot, adduction of the hip and hyperextension of the knee. Functionally she was independent with bed mobility and sitting balance, supervision for transfers and non ambulant on initial assessment. Her right lower limb, trunk and upper limbs were unaffected.

Subjectively, it was noted that the patient had catastrophising behaviours and was concerned about the lack of a diagnosis and prognosis.

The medical team, from lack of a clearer picture, and inability to find anything on clinical tests, diagnosed this patient with transverse myelitis, or inflammation of the spinal cord. For this she was started on steroid therapy to decrease the potential inflammation and hopefully alleviate some her symptoms.

TASK

In this situation it was my role to investigate this patients past medical history and relevant information from her medical file. From this I was too conduct a full neurological and mobility assessment to help develop an appropriate rehabilitation plan in the future.

ACTION

From reading the patient’s medical notes, it was unclear as to the cause of her symptoms and there was no indication of a diagnosis. To clarify this I met with her medical team to discuss her notes and their point of view of her situation before I went and had a look for myself. The medical team confirmed that all tests had so far been negative and they thought this could potentially be an acute attack of multiple sclerosis, though without evidence of plaques or prior episodes, this diagnosis could not be made. They felt that with a thorough physio assessment, the symptoms would be clearer and they could get a better understanding of her presentation.

I proceeded to conduct my assessment of the patient. On subjective questioning of the patient I gathered the relevant information about onset, history, current understanding and feelings and goals. This also helped me develop rapport with the patient as she was quite concerned and anxious about her pending diagnosis and sudden onset of muscle weakness with abnormal sensation. Being on a specialised neurology/stroke ward didn’t reassure her in the least, fearing she had experiences a stroke or had developed a brain disorder of some kind. I explained the process of assessment and how this would aid the medical team in the diagnosis, which would further help her rehabilitation, as we would understand how to manage her symptoms.

The assessment was carried out, with constant explanation and reassurance to the patient, as she was concerned about the impairments and their potential meanings. This included; muscle power, tone, detailed assessment of sensation, coordination, reflexes and functional capacity.

From my findings I had a feeling that this could potentially be an acute episode of multiple sclerosis; the patient reported that she had experienced clonus in her lower limb in the past and had tingling sensations in her upper limbs though didn’t think anything of it, the symptoms were unilateral and of quite an original nature and the symptoms seemed to have changed rapidly from onset to admission to the time of the assessment. This thought was not expressed to the patient and instead I discussed my findings with the medical team who agreed that they felt the same way, though as it was the first recorded episode, the diagnosis could not be made. Therefore they were planning to diagnose her with Transverse Myelitis. I received the okay to commence rehabilitation.

From this I then explained the diagnosis to the patient who had been informed by the medical team earlier that day, and also explained the effects of the steroid treatment she was to commence. We then collaboratively developed short term and long-term goals and a rehabilitation plan.

RESULTS

As a result of my assessment, the medical team was able to confirm the patient’s presentation and get a better understanding of her clinical picture. I was also able to develop an effective and targeted rehabilitation program with the patient to impact on her impairments.

Through effective communication I was able to develop a good relationship and rapport with the patient, which gave her confidence in my ability as her therapist and my future planning. My explanations also helped the patient understand her symptoms and treatment and she was better able to participate and grasp the concepts of her rehabilitation, making it easier to undertake treatment.

EVALUATION

With this particular patient, my biggest strength was communication. Coupled with this was compassion. Without being able to relate to this patient and truly portray empathy for her situation, I feel assessment and treatment would not have been so effective and the patient would have been swept away by her catastrophising beliefs. By giving her understanding, this gave her a sense of control, which gave me confidence in that she would be proactive in rehabilitation and motivated to participate at 110%.

Another strength was my thorough assessment and efficiency of conducting this. This also benefitted the patient as it built her confidence in me as her therapist. As it was my 5^th week and probably my 30^th full neuro assessment, I had developed a method that came naturally and easily.

A noted weakness was confidence in communicating with the medical team. In this particular situation I felt they handled the patients catastrophisation poorly after recommending she take part in a medical student study and be a case study they examined, which involved a room full of medical students trying to guess her diagnosis. After which the patient was clearly distraught by the suggestions made and spent an afternoon in tears. They also explained the findings of tests, eventual diagnosis and steroid treatment. I expressed this to my supervisor who said it is often left to the allied health team to translate medical information to the patients as they are often pushed for time.

STRATEGIES

Some strategies that were / could be useful in similar situations are:

- Building rapport with your patients through understanding and empathising. Also having good prior knowledge of their situation and researching elements of their history prior to seeing them gives an extra head start before seeing the patient.

- Planning assessment before going in, though avoiding having expectations as this could bias your interpretation of results.

- Utilising the knowledge of the whole multidisciplinary team and having confidence in own background to backup and present your argument in any open discussion.

STARES 2

SITUATION

A 37year old female was diagnosed with multiple sclerosis at the age of 27years old. This patient had suffered frequent relapses in multiple sclerosis with a variety of presentations, including complete blindness, paralysis and incontinence. She presented to Royal Perth hospital under the recommendation of her neurologist when her latest episode failed to relinquish and seemed to be progressing. Early in May she reported waking up with loss of strength in her right lower limb. This further progressed in the week to a radiating “electric shock” sensation to touch, throughout the left side, below the T4 dermatome. On admission, an initial mobility screen and assessment was completed. From the subjective it was found that she had struggled with multiple sclerosis for 10 years. In this time she had had numerous relapses with some residual deficits including impaired sensation in her upper limbs. As well as this struggle against the unknown, on her journey she had discovered that she is immune-deficient and has severe life threatening reactions to most multiple sclerosis control medication. Her lifestyle choices like smoking and unhealthy diet, regular hospital admissions, steroid treatment and past wheelchair dependency for periods at a time, she had become obese. With the additional weight and regular steroid treatment, rehabilitation became very difficult and limited severely by fatigue. She had also had bad experiences with rehabilitation in the past, with little input and persistence, she had been deemed wheelchair dependent by her therapists. She then taught herself to walk independently at home, which resulted in shattered knee-caps and hip injury from repeated falls. Coming to Royal Perth she was astounded at the amount and quality of input she was receiving. On admission she was ambulating with a family walking stick and one assist for short distances, otherwise she used her wheel chair. On ambulation she had a poor pattern with excessive compensation. Rather than using the walking stick as an effective aid, it was used like a tripod to extend her base of support. From this we incorporated gait re-training as a fundamental component of her rehab. Upon discharge she was referred to Shenton Park campus for further inpatient rehabilitation.

TASK

For this patient, my task was to conduct a thorough subjective and objective examination to ascertain the full clinical picture. From this I was to develop a treatment plan with options to modify as her clinical presentation was changing slightly day by day. After 2 weeks of rehabilitation I had the task of planning her discharge and referring her to Shenton Park Campus.

ACTION

On commencement of the examination, I discovered through the subjective that she had a poor history with her therapists. I therefore took a sensitive approach to her history and struggle with her condition and thoroughly explained the process of examination and rehabilitation offered at Royal Perth. After gathering a clear clinical picture of this patient, with extensive questioning I conducted a brief neuro screen, assessing tone, sensation, proprioception, strength and coordination. I then began a mobility screen, starting with bed mobility, transfers and finally ambulation. I found she was independent with bed mobility and transfers, though required excessive effort to complete the tasks. On ambulation, I had to educate her on technique and aid use. From observation of her pattern I deemed it more appropriate for her to use a wheeled zimmer frame to provide the additional support and balance that she required to demonstrate a more efficient gait pattern. This mobility screen fatigued the patient. I discussed fatigue with the patient and educated her on knowing her limitations. We then organised an appropriate time to begin treatment the following day, at a time when she felt she had the most energy.

I devised a treatment plan to address her fear of the forward space, lack of trunkal dissociation and control, standing balance and foot awareness. With this treatment plan was a few other options or avenues we could try if the first idea wasn’t optimal. We commenced treatment the following morning, ensuring all treatments were related back to functional gains to provide motivation for participation. The patient worked well and at the onset of fatigue I took the patient back to her room. I prescribed her with an exercise program to continue in her room throughout the day when she was feeling up to it.

We continued rehabilitation throughout her stay, progressing her exercises to continually challenge her. I developed good rapport with the patient and we worked well together.

The multidisciplinary team discussed her discharge options and it was globally decided that further rehabilitation at Shenton Park was optimal. I discussed this with the patient and she was eager to begin. I completed her discharge summary and contacted Shenton Park to relay the relevant information.

RESULT

As a result of my assessment, I was able to coordinate an effective treatment plan and carry this out with my patient with success. With constant re-assessment and regular input we were able to progress her rehabilitation throughout her stay and improve her independence with transfers and her effectiveness in gait. We developed a good rapport and understanding and I feel this helped with her rehabilitation and acceptance of therapy input. She participated in her therapy sessions and from what I gathered, carried out her exercise program, this optimised her chance of recovery. My supervisor was satisfied with my performance with this patient and was confident with my approach, therefore allowed me to conduct majority of sessions independently. She was also pleased with my discharge planning and supported me in the decision to refer this patient to Shenton Park for further input.

EVALUATION

In this clinical situation I feel I communicated well and my ability to build rapport and understanding with this patient was good. With prior experience and knowledge of multiple sclerosis, this gave me an advantage in understanding the patients struggle and I was able to adequately relate to her difficulties.

My treatment plans were appropriate in their level and difficulty. They were challenging yet achievable, therefore the patient was satisfied with their performance and motivated to continue with therapy.

Elements I could improve on would be my questioning throughout the subjective as I feel there were crucial elements I didn’t thoroughly explore and gain a clear enough picture of. Throughout our treatment sessions, I was able to ascertain this information.

Also my confidence in the multidisciplinary team meetings could do with improvement. During the meeting I was asked for my input on the patients status in physiotherapy. I gave an overview of her mobility, her key issues that we were working on, and what we were doing specifically in treatment sessions. My supervisor then provided the additional information that I failed to mention of rehab potential and our plan to recommend Shenton Park.

STRATEGIES

Having multiple treatment strategies worked to my advantage, as I was able to modify my treatment sessions depending on the patients level of symptoms and alertness. An independent exercise program for the patient to do independently is also a strategy I will employ in the future as this gave my patient a degree of control over their rehabilitation and gains and I feel also improved the gains we made as she was practising what we did in our sessions throughout the day.

Breaking the subjective down into components that are easier to comprehend and handle would improve my efficiency in questioning.

Lastly preparing fundamental information that needs to be relayed in the team meeting for each of my patients would be handy to improve my confidence in these situations.

STARES 1

SITUATION:

A patient was transferred from the ED department to the neurology ward for further treatment. She had presented to the ED department complaining of a severe headache behind her right eye and a sense of vagueness and confusion. This was later diagnosed on CT scan as a haemorrhagic stroke in her right frontal lobe. On initial admission, the patient was medically unstable, therefore only the necessary mobility screen could be carried out on day one. Initially she required two people to assist transfers and could only step stand transfer over the right side. Her sitting balance was poor, standing balance almost non-existent and she was not ambulating. By day two, there was lingering drowsiness, though she was now medically stable and her headache had eased. A neuro assessment was commenced and it was found that she had a low affect, significant rigidity throughout her right side, lower and upper limb, mild problem with initiation of movement, reduced ROM in her right shoulder secondary to a rotator cuff repair a few months prior, poor postural control and poor pelvic, lower limb and trunk dissociation. On the Gowland assessment she scored level 6 on most parts. Day three her presentation had changed again. She was now requiring one assist to transfer and ambulating in physiotherapy only with maximal assist of one.

TASK

My task in this situation was to conduct the initial mobility screen of this patient, complete a full initial neuro assessment and plan and carry out daily physiotherapy sessions.

ACTION

After I had conducted the initial assessment and developed a problem list for this patient, I developed some ideas for treatment and presented this to my supervisor. We were in disagreement in the approach to this patient as I was adopting a more functional approach, where as my supervisor wanted to address the impairments specifically. I carried out a fairly standard treatment session addressing impairments, which incorporated bridging and trunk control activities in supine, encouraging glute activation. I then finished this session with a facilitated walk. As she had a haemorrhagic stroke, her presentation was highly variable and by day four, Friday, she was requiring moderate assist of one for transfers and ambulation. My treatment focus then turned to addressing her pelvic control in standing and her confidence towards the forward space to bring her centre of mass in front of her base of support, making sit to stand transfers and walking easier.

RESULTS

My supervisor didn’t encourage walking this patient, though after seeing me walk her in my treatment session with the tutor, she identified that with appropriate facilitation, her gait pattern was near normal. I was able to show my supervisor that my observation of this patient’s ability was good and the treatments I had chosen were suitable. Focusing treatment on a functional task involved the patient more as she understood the relevance of the activity. This also boosted her confidence in recovery and physiotherapy.

EVALUATION

It has been difficult to build rapport with my supervisor on this placement as I feel a functional approach in some cases is more appropriate than addressing impairments specifically. When the functional ability of a patient is high, I feel that the impairments can be addressed through fine-tuning of the functional tasks rather than taking the patient to a non-specific task that addresses the impairment in isolation. In this particular situation I had this difficulty. Though I was able to see this patient with my tutor who agreed with my decision to walk this patient, which was fairly successful. Something I could perhaps improve on is my confidence in my ideas and ability to translate this to my supervisor.

Also my neuro assessment wasn’t systematic and it was obvious that this was my first experience with this. This is something I will need to work on and practice to improve my efficiency in assessment.

My communication to my patient was appropriate and effective. I found it easy to develop rapport and engage the patient in treatment. Another element I need to work on is facilitation. This again comes with experience.

STRATEGIES

- Relate all treatments to tasks that the patient find relevant to their goals. This helps with engagement of the patient in treatment sessions

- Confidence in observations and treatment ideas to relay this to my supervisor.

- Planning assessment in order of position eg. Supine tests, sitting tests, standing etc. This improves the flow and efficiency of the assessment process.

Initial Entry - Royal Perth WSC Stroke unit

In anticipation of my third clinical placement at Royal Perth Hospital I have begun preparation for a highly demanding five weeks. From my peers I have heard that generally placements at Royal Perth are challenging, in that expectations of knowledge and ability are of the highest standard and that staff tend to derogate students. Combined with this feedback, is a pre-warning that my potential supervisor can appear to be “a bully.” With this in mind I am anxious, again. The sense of unknown is un-nerving and with the feedback I have received about this placement, it has not been comforting. As I am coming into this placement on such a high from my last placement, I feel this could work to my advantage as this has built my confidence.

Royal Perth is a hospital in the public sector. I am assuming this will be run like most hospitals in that there will be a high focus on the multi-disciplinary team and a more or less blanket referral of patients to the wards physiotherapist. As I have had prior placements on wards in hospitals, I am confident that I will know the structure and procedures in how the ward operates. I have also had practice in writing inpatient notes etc, so this should alleviate some initial pressure.

For this placement specifically, I have revised my neuro, in particular stroke symptoms and presentations as well as neuro assessments. I am hoping this is sufficient to get me through the first couple if days, until I get an idea of specific knowledge that is required from me.

I feel my role in this placement will be to support the existing structure, participate in the multidisciplinary treatment of patients and conduct myself professionally as a potential future physiotherapist.

Prior to commencing this placement I have the following concerns:

- That I will not be able to establish a positive learning relationship with my supervisor.

- There could potentially be barriers in terms of negative attitudes towards students, impairing my ability to gain a lot from the placement through interaction with colleagues.

- With little experience with stroke patients, I may appear inexperienced and uncoordinated in this area.

Overall I am most nervous about this placement, as it is a field I feel I have the littlest experience with and from the feedback I have received I will have barriers to overcome. I am also anxious that if I feel overly intimidated I may be less inclined to take advantage of learning opportunities, as I will be afraid to ask. With the support of the Notre Dame staff, that I can rely on if things become too overwhelming, hopefully I will be able to overcome any unnecessary anxiety and awkward situations I may fond myself in.

FINAL ENTRY - AMR Physiotherapy

Five weeks of rural physiotherapy in Margaret River has been a blast! The placement gave me invaluable experiences in a broad range of physiotherapy fields, including musculoskeletal, gerontology, neuro, paediatrics and cardiorespiratory, in both a private clinic and public hospital setting. Having such a vast array of clinical presentations kept me on my toes, always wondering what would be next.

Three days of the week were spent in the private sector at AMR physiotherapy, a private practice. Here the case mix was broad, from children with trampoline injuries and wine makers with low back pain to yoga students with knee strains and surfers with complete gastroc tears. The rest of the week was spent in Augusta, housing a somewhat older population. I got close with the members of the community, having one on one physiotherapy sessions as well as weekly exercise groups and outings.

Looking back at my initial entry, my perception of this placement is the same, if not better. I have thoroughly enjoyed the atmosphere and the unpredictable nature of the rural setting whilst expanding my clinical experience greatly. My initial anxiety subsided within the first week, after meeting my friendly and supportive supervisor and treating some amazing patients who appreciated the extra time spent with them, as well as learning a lot themselves from my learning.

The issues I had to prior to commencing this placement were dealt with throughout the five weeks and by the end I felt very comfortable, reluctant to leave.

To start with I had concerns about my ability to recall information from my studies to apply this to my patient. In the clinical setting, it seems to come naturally and the lectures become clear and relevant. My supervisor was also very supportive with a broad knowledge base and over 30 years of experience in physiotherapy. Even if I was unsure of a test or technique, he would always be close by to assist, or show me a completely different approach to broaden my skills. The close supervision was nerve racking for the first couple of days, though as my confidence grew, so did my supervisors confidence in me and he took a back seat in the sessions, only giving input if I asked or he felt it was absolutely necessary.

The only issue that I had throughout the placement was physical ability. I often came against the problem that I could not overpower my patient in a strength or muscle power test, nor did I have the arm span or size to perform some techniques. My supervisor was very understanding and supportive in this area and taught me some strategies to overcome this, which I employed throughout my time there and this gradually became a less evident issue. I also found that some of my own physical faults, for example internally rotated and valgus knees, became evident when trying to teach a patient how to perform a certain task correctly, like squats. This is something I will continue to face, and hopefully with live what I preach and correct such postural anomalies.

Overall I have enjoyed this experience and have restored my confidence as a physiotherapy student. Having a supportive and welcoming supervisor makes all the difference when on clinical placement and I feel this is 80% the reason I have enjoyed this prac as much as I have.

Musculoskeletal private practice physiotherapy is a great area to work in, and I felt comfortable in my skills and performance in this area.

STARES 3

SITUATION

In my final week at AMR physiotherapy I was acting as an independent practitioner, seeing my own patients individually. A particular patient I saw, referred to physiotherapy by his school, was a 5 year old boy complaining of knee and hip pain when running and walking. Informally observing his posture and gait, the following was noted; bilateral pronation of the feet, internally rotated hips bilaterally, valgus knees and wide stance. By questioning the mother and son it was evident that the pain was worst with running and had been gradually worsening over the past month. The boy felt his left was sorer than the right and that it was mainly his knees that hurt. On formal examination it was evident his feet were over pronated with complete loss of arch, though he was able to actively achieve one, his knees were in valgus; left greater than right, he had adopted an abnormal gait pattern and there was no evidence of a leg length discrepancy. The mother had been in correspondence with the school in regards to the complaints of pain and teacher had observed the flat foot posture and recommended physiotherapy as an appropriate place to seek advice for treatment. The mother had also done research into flat foot posture in children and had become quite anxious about potential surgical treatments and outcomes.

TASK

My task in this situation was to ascertain the source of the pain by acquiring information from the teacher's referral as well as the young boy and his mother and perform a thorough examination. I was also required to establish the activity limitations and goals to make future treatment as functional and meaningful as possible.

ACTION

On subjective examination, I initially spoke directly to the child, building rapport by asking about school etc. From this I gradually became more specific, asking about what he was experiencing when he ran and exploring his thoughts. From the information I gathered from the boy, I then proceeded to confer these details with his mother and her perspective of his pain. This provided me with valuable information about where the pain was, what aggravated the pain, what had already been done and what the mother felt would help. Using the information I had retrieved, I began my objective assessment. This included postural and gait analysis, as well as specific tests of the knee, hip, ankles and feet. My supervisor assisted me in this element of the assessment, and he performed additional tests he had acquired over his physiotherapy career.

After the examination, we concluded that the main source was the altered foot posture, overly pronating affecting knee and hip alignment. I then instructed the boy through active supination by trying not to squash an egg that he had to keep safe under his foot. This was a game that I showed the mother to continue at home as often as possible.

On speaking with the mother I noticed her anxiety towards the pain her son was experiencing and possible surgical interventions that had been suggested on the internet. I reassured her that considering she had noticed it so early, children can change and adapt rapidly, so with correct input we would be able to make significant improvements. This alleviated some of her anxiety and she left feeling confident that she was on the right path to resolve the issue.

RESULT

As a result of this session, we had a clear understanding of the issue at hand and had a rough plan of our future treatment approach. I had also reassured the mother to reduce her anxiety, which also reduced anxiety in the child.

EVALUATION

In this session I was able to effectively build rapport with the mother and child through effective communication and a good approach. This rapport then translated into the assessment, and the boy was willing and trusting to allow me to do the assessments I needed to do.

My objective examination was less fluid, as I was unsure of which assessments were applicable. I also found it difficult to keep an open mind to any other underlying impairments, as the pronation and altered posture was so obvious.

In this situation I had a few treatment ideas that I had acquired from Notre Dame practical lessons, so was able to instruct the boy on how to perform these and give a few suggestions of running at the beach and wearing thongs as other strategies to encourage altered foot posture.

STRATEGIES

A strategy I found useful was starting the session with general conversation about school and friends to build rapport with the child. It is important that the child feels comfortable with you, especially when you will be asking the child to de-robe and be performing assessments on them. In future I will have a better knowledge of this impairment as I have now seen it presented clinically, so will be able to perform the objective examination in a more efficient and effective manner. Another strategy crucial to a good clinician is keeping an open mind, to discover all underlying impairments and get a whole picture of the patient in front of you rather than putting all presentations to text book as everyone is an individual.

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.