Week Three

Situation: This week I was presented with a 26-year-old male complaining of right groin pain. He had a referral from a doctor, which asked to treat his right rectus femoris as he suspected a possible tear. The patient revealed he had sustained a fall off his motorbike 8 days ago onto his back and head, lost consciousness, was sent to the emergency room and had an MRI the day before and did not know of the results.

Task: To perform a subjective history taking assessment, in order to formulate a diagnosis and plan a suitable treatment plan to address his groin pain.

Action: I performed my initial subjective history taking to find that rectus femoris may not be the source of the groin pain as he didn’t complain of pain and was able to do a full squat. My supervisor then retrieved the MRI results, which revealed he had sustained a fracture of the acetabulum and labral separation. As he presented as unsuitable for physio at the present time, with the help of my supervisor, I educated the patient on where the fracture was sustained and addressed his concerns about being able to work.

Result: As he was not suitable for physio, education and advice was the only form of treatment that could be undertaken at the time. The patient was disappointed with the outcome and the knowledge that he may have to undergo surgery and be unable to work at the current time.

Evaluation: The issue I had with the subjective assessment was the detail I was able to gather and record in a short amount of time. I was more focused on addressing the groin pain issue, and did not consider the mechanism of injury as a critical factor in the diagnosis. However, he didn’t present with typical signs of fracture as he was weight bearing and didn’t complain of high pain levels. I found this case very complex and was overwhelmed with the information, and was unable to organise my thoughts and record all the critical details necessary, which made the initial assessment poor.

Strategies: I need to listen more carefully and analyse the overall situation as opposed to focusing on the presenting condition. I also need to learn how to gather more detail by asking more specific questions in order to formulate a more accurate diagnosis. I hope to employ these subjective assessment taking strategies in the next two weeks to improve on my subjective history taking.