Week One

S: My patient was a 57 year old male that had a cerebellar cyst removal 2/12 ago. He had signs of left cerebellar ataxia and was referred as an outpatient for gait re-education and balance retraining. His past medical history included removal of his right gluteus, and removal of pelvic tumours.

T: To perform a full neurological assessment and treatment plan for this patient.

A: I used a musculoskeletal outpatient proforma as well as a neurological assessment form. I gathered the relevant history, patient goals, and determined the relevant functional impairments that needed improving.

R: Despite the information on the referral, the client upon assessment did not show obvious signs of cerebellar ataxia. There was a mild intention tremor on the left and gait was impaired as the patient had become accustomed to walking with knees bent after the removal of his glut as there was no hip extension on the right lower limb. High level balance was also impaired and this was focused on in treatment along with gait re-education promoting heel strike on the initial contact phase.

E: As this was my first outpatient, and neuro patient as well, I was quite nervous. After going through the assessment and there were no obvious asterisk signs or stereotypical cerebellar signs as I was expecting, when it came to treatment planning I felt stuck as to where to proceed from that point.

S: Strategies I used to help me with this patient was I seeking advice through my supervisor throughout my assessment and treatment. My supervisor was able to help guide my treatment planning.