Anne's Blog

Week 3

2011-07-17T03:31:00.000-07:00

S: 68 year old female presenting with neck pain. She has had a history of recurring episodes of neck pain throughout her life but have been self resolving. She has not required any management until this most recent episode lasting 4 months. She has no relevant past medical history or any medical conditions. The neck pain has been affecting her range of motion looking behind her right shoulder while checking her blind spot, looking up, and she is unable to roll over in bed without sitting upright first. She described her neck pain as a constant ache varying between a 3-4/10 pain.

T: perform a full subjective, objective, and appropriate treatment.

A: I took the relevant subjective history and completed a full objective assessment. I was able to establish that C3/4 was the level producing her pain and was limited into extension and right rotation. I then performed a passive accessory technique to improve right rotation and extension.

R: On reassessment of her active range of motion, there was a significant improvement in the range into right sided rotation. The treatment did not have much effect on pain which was to be expected as the technique was into the provocative direction.

E: I think I chose the appropriate treatment technique although provocative to use for this patient. I was able to find the level reproducing the pain and restricting the range of movement. I do think that my assessment technique for motion palpation needs improvement as I am unsure at times how to assess what I am palpating.

S: I asked my supervisor to perform a motion palpation on the patient as well and then discussed with him before I continued on to a treatment. This way, I was able to compare the findings and see if my assessment was accurate. I also discussed the most appropriate technique before choosing it. I found it easier to brainstorm ideas with my supervisor first and then perform them.

Week 1

2011-07-03T06:02:00.000-07:00

S: 22 year old female presenting with a three month history of thoracic spine pain. The patient has a history of lower back pain, and was currently unemployed as a result. The presentation consisted of constant thoracic spine pain, pain with coughing, and night pain. The patient has no other relevant past medical history.

T: Perform a subjective, objective and appropriate treatment.

A: After taking the subjective history, there were obvious red flags. I did not wish to proceed further with any objective examination or treatment as I did not feel it was appropriate. Instead, I advised the patient to go back to her GP and seek medical advice on the situation and suggested a scan may be appropriate at the doctor's discretion.

R: The patient agreed to my advice. I wrote a letter to the patient's doctor with the subjective examination findings and the suggestion that further investigation may be appropriate. I am unsure as to the result of these at the current time.

E: I was quite nervous once hearing the subjective history, as this was the first time I had encountered 'red flags'. I also did not want to appear as though there was major concern and I think I kept proffessional during the session. I feel I expressed my concern for further investigation in a calm proffessional manner, and not to worry the patient.

S: I seeked advice from my supervisor following the subjective, although he left it to my discretion. I told him I would refer the patient back to the GP and he agreed that was the appropriate decision. He did ask me to complete an objective examination, although it would be limited.

Initial Entry

2011-06-26T03:44:00.000-07:00

My initial thoughts for my last rotation are of excitement as the year is coming to an end, as well as the fact that this rotation is a musculoskeletal placement. I am looking forward to this rotation as I have not had much clinical experience in the musculoskeletal area and I would eventually like to work in this field once I graduate.
I think as a final year physio student, I will have a greater role in this field as oppose to other areas. I am hoping to be able to manage a full caseload by the end of the placement. As this is the area I wish to work in once graduated, I’m hoping I will be able to consolidate my communication skills, clinical reasoning skills as well as my manual therapy techniques.
I am slightly nervous and apprehensive about this placement, as I haven’t had much hands on clinical experience in the area, and I’m not sure how great my manual techniques are. However, I am hoping during these five weeks I will be able to refine them and be able to apply them effectively. I’m not sure as to the level of supervision I will receive on this placement. I am hoping in the early days I will be able to sit in a few sessions, as well as have a small caseload of my own and then progress from there.
I have revised musculoskeletal techniques, but I am also hoping to learn other alternatives to types of treatments that may be more beneficial to specific types of patients.
By the end of the placement, I am hoping to be confident in the musculoskeletal field, be able to manage a caseload independently, refine my manual therapy techniques, as well as gain insight and additional knowledge in the area.

Final Entry

2011-06-19T05:32:00.000-07:00

At the end of my five weeks of my cardio placement, I have successfully learnt how to assess and treat a surgical cardiac patient. Although, I was not able to run the ward, I was able to manage an individual case load.

Throughout the placement, I consolidated my communication skills. I was able to provide pre-operative and pre-discharge education to a group of patients at one time. I was able to answer questions confidently which, in turn, consolidated my theoretical knowledge. I also further developed my skills in working with other members of the allied health team, liaising and working with team members more closely with specific patients.

My weakness on this placement I feel was time management. As I was not familiar with mobilising patients with a multitiude of attatchments, I found I struggled with time whilst setting up the patient's attatchments before mobilising. However, by the end of the five weeks, I was able to mobilise a patient with attatchments more efficiently than I was towards the beginning of the placement.

I also was not given the opportunity to run the ward, so I am still uncertain as to whether I would be able to manage a larger caseload than I was given, particularly in terms of time management.

I did however consolidate my theoretical and practical skills, and by the end of the placement, I was able to treat more acute patients in intensive care. I feel more confident being able to assess and treat patients in the cardiorespiratory area and have learnt more theoretical knowledge in a practical setting.

WEEK 5

2011-06-19T05:07:00.000-07:00

S: 75 year old male presented to hospital with severe ongoing chest pain. The patient has a past medical history of chronic obstructive pulmonary disease, angina, triple vessel disease, and hypotension. He lives in a caravan park with his wife, who is 91 years old and resistant to services or assistance. He was previously walking ~10 metres within the home with a walking stick.

T: To perform a full subjective history and appropriate treatment for the patient.

A: I asked the patient numerous relevant subjective questions regarding the patient's home living situation, smoking history, cough and sputum production, and previous level of mobility. I took the patient's relevant objective measures such as auscultation, oxygen saturation levels, blood pressure and heart rate. I then asked the patient to sit over the edge of the bed, which the patient refused. I then comprimised with the patient and positined him into high sitting, and gave the patient deep breathing exercises to perform throughout the day independently.

R: I was able to obtain a thorough subjective history from the patient, which the patient was willing to answer. However, the patient refused to sit out of bed despite me emphasising the importance. I was able to achieve an effective treatment session, however it was not optimal as the patient was refusing to participate.

E: I think overall, although the session was not the best treatment I could have done, I think I was able to at least achieve an effective treatment. The patient was refusing to participate in any physical treatment which made the session difficult, however I think I handled the situation well providing an alternative which enabled me to achieve something out of the session.

S: I consulted with my supervisor, who agreed to take a similar approach as I did in dealing with a patient that was refusing to participate in physio.

Week 3

2011-06-05T23:59:00.001-07:00

S: 79 year old male admitted to hospital with 8 weeks of sharp abdominal pain, frequent toileting and diarrhoea. The patient underwent a laparotomy procedure, his past medical history included bilateral total hip replacements and removal of a parotid tumour in 2010. He lives with his wife and was previously independent with his mobility and self caring.

T: Perform a subjective history, objective and appropriate treatment for the patient day 1 after the laparotomy procedure.

A: I performed a full thorough subjective and objective assessment. The patient however would not allow me to mobilise him as he was beginning to become quite aggressive and agitated. I then taught the patient bed exercises, deep breathing exercises and a supported cough to perform hourly as an intervention. I also educated the patient on using the pain relief as required to allow the exercises to be performed.

R: I was able to gather a detailed history from the patient. All of the patient’s objective measures such as blood pressure, heart rate, and respiratory rate were within normal limits. The patient’s chest was clear on assessment and the patient had a dry strong cough but was inhibited by pain. As the patient was quite agitated and aggressive towards the end of the session, I was not able to sit the patient over the edge of the bed due to not having consent.

E: Overall, I think I achieved the most I could have out of the session. I was able to try and reason with the patient to do the deep breathing exercises and bed exercises instead of sitting him up and he reluctantly agreed. Reflecting on the session, I think shortening my subjective history taking may have reduced the level of agitation and aggression of the patient. However, at the time of taking the history, the patient was very compliant and there was only a sudden change of behaviour once I began explaining the intervention. Although the session did not go as planned, I was able to provide an intervention, even if it was not the most optimal for the patient.

S: I asked my university tutor for some advice on handling the situation where the patient is non compliant. I compromised with the patient providing an alternative to my initial intervention aim of sitting over the edge of the bed instead which was successful.

Week 1

2011-05-22T01:26:00.000-07:00

S: The patient is a 61 year old male admitted to the ward following a coronary artery bypass graft surgery. The patient has an extensive smoking history of 20 cigarettes a day for 50 years. The patient is from the country and lives with a work colleague. The patient was previously independent with all mobility and domestic duties. He is a self employed brick layer.

T: Perform an assessment and treatment for the patient

A: I checked the patient’s chest, and then re-educated the patient on deep breathing exercises and a supported cough. I then monitored the patient’s oxygen saturation levels with and without the use of oxygen. I took the patient for a short walk without the use of oxygen but took a portable oxygen trolley just in case it was needed.

R: The patient managed the walk however his oxygen saturation levels decreased to 86% off the oxygen. I then asked the patient to rest and take deep breaths in an attempt to increase the oxygen levels. The oxygen level only improved to 91% so I then placed the patient on oxygen and returned the patient to the room where I continued to do deep breathing exercises with the patient.

E: I think I managed the situation appropriately. I was able to determine when it was appropriate to place the patient back on oxygen and cease the session. It was challenging as the patient was not showing any signs of respiratory distress but I took the necessary precautions to make sure my session was safe.

S: I asked my supervisor when it would be appropriate to place the patient back on the oxygen even if they were asymptomatic. I also liaised with the med team regarding the levels of oxygen they were happy with for the patient to be off the oxygen.

Initial Entry

2011-05-15T02:33:00.000-07:00

It is the third rotation for fourth year placement and the area in focus is cardio. I feel a bit nervous about this placement, however as I have had some experience in cardio in my previous placements I do not feel as nervous as I was at the beginning of the year. I think the placement will allow me to gain further skills as well as consolidate my previous knowledge in the area. I hope that I will be able to be more confident during this placement and have more initiative with liaising with other multidisciplinary team members.

I think my role as a 4th year student will be to manage a caseload independently. I think that initially I will have supervision and help from the supervisor, which will allow me to gauge an idea of how the facility runs. I will need to ask many questions regarding discharge planning, average length of stay and the style of note writing the facility prefer.

My major concern about the placement initially is what types of patients I will be treating as I am unsure what particular ward I will be on. This is making me a bit nervous, as I don’t feel as well prepared as I would if I knew what the specific area was going to be. Nonetheless, I am hoping I will have enough knowledge as a 4th year to be able to apply to any type of setting and I will then research any uncertainties I have.

Overall, I am looking forward to furthering my knowledge and skills during this placement in order to become a more experienced and confident physiotherapist.

Final entry

2011-05-01T07:15:00.000-07:00

The last five weeks of placement have been very challenging and educational. I was very overwhelmed within the first few weeks of placement as it was neurosurgery. I found the first week to be very confronting witnessing the types of behaviours associated with head injured patients. I also found it difficult to treat a patient that did not open their eyes or respond to me as I was used to dealing with quite well and mobile patients.

As the weeks progressed and I was given more of a role as a physio with patients, I struggled with keeping the flow of sessions as I felt flustered when I wasn't able to perform the planned treatment or assessment due to the behavioural issues.

By the end of the placement and having input from the uni supervisor as well as another well experienced physio, I was able to broaden my treatment ideas and carry out more effective treatment sessions as I felt more confident. I was able to redirect sessions when patients became distracted or agitated and I was also able to carry out sessions when the patients did not participate due to being in a stuperosed state.

Overall, after this placement I feel more confident within my skills as a physio being communication particularly as well as types of treatment techniques for head injured patients which can also be transferred to stroke as the presentation can be quite similar physically. I felt more confident by the end of the placement and feel I would be able to manage a case load for the neurosurgery population effectively.

Week 5

2011-05-01T06:58:00.000-07:00

S: 44 year old indigenous male 3 weeks post collapse with left and right intraventricular bleeds and associated left sided hemiplegia. Past medical history included diabetes, obesity, hypertension, alcohol abuse, and smoking. The patient (pt) has no fixed address, occasionally stays with brother, pt unemployed. Current Glasgow coma scale score (GCS) of 3/15 trache in situ and oxygen saturation 98% on 2L of oxygen via swedish nose.

T: Perform appropriate assessment and treatment session for the patient.

A: I performed relevant assessments needed such as GCS, chest, passive range and tone assessment to direct my treatment. As the patient was in a stuperosed state, I was able to perform suctioning via trache, passive range to provide some proprioceptive input and stretching to avoid contractures due to abnormal tone. I then did rolling to provide vestibular stimulation as the patient was unable to be sat out of bed due to continual opening of bowels.

R: The treatment session was effective overall. I was able to clear secretions via suctioning allowing increased breath sounds throughout upon reausculatation.

E: I struggled with passive range exercises as the patient was obese, and also particularly because the patient was in a stuperosed state and had no voluntary control of any limbs, I found it physically demanding. I struggled to find an appropriate position to perform these exercises in without placing my back at risk.

S: I seeked help from the supervising physio. He was able to show me different ways of handling the patients limbs. However, it also was suggested by the physio that if it was too physically demanding, I would not be able to continue to see the patient. I was able to utilise these different positions effectively and safely and was able to continue to see the patient.

Week 3

2011-04-18T04:23:00.000-07:00

S: 83 year old male presented with acute dysarthria and right sided weakness following a fall one day ago. Patient (pt) is the primary carer for his wife who has dementia. Primarily Macedonian speaking and English as a second language. Previously independent with all duties and ambulating independently. Past medical history includes hypertension and carotid stenosis. Pt sustained left subdural haemorrhage and underwent a craniotomy and evacuation. T: Perform a full neuro assessment for the patient including tone, passive range, GCS, mobility and cranial nerves. A: I measured the pt’s range of motion, established an appropriate form of communication, measured tone and performed a mobility assessment to handover to the nursing staff. R: I was able to carry out a thorough neuro assessment. The pts range was within normal limits, cranial nerves were intact, the pt required 2 people to assist with bed mobility and maintaining sitting balance so the patient was not for ambulation. The patient was also set up with a stock wheelchair to be hoisted out of bed into daily as the patient was not for transfers. E: The patient tolerated well although it was hard to communicate with the pt initially as only short clear commands were understood and I was unable to explain the reasoning or educate the patient on the role and purpose for physio. This also altered the pt's GCS level due to confusion as a result of the language barrier. S: I asked my supervisor for feedback after the assessment and I was able to attain better forms of communication particularly with a head injury and also a pt that does not primarily speak English. I then used these for further treatment sessions throughout the week with good effect.

Week One

2011-04-02T23:32:00.001-07:00

S: 75 yr old male post intraventricular bleed found collapsed in home by wife ?fall ?collapse ?duration. Patient (Pt) was on warfarin increasing the bleed. Pt treated with extraventricular drain to remove bleed. Pt previously ambulant. Pt has history of asbestosis. Pt currently trache in situ and decuffing regime currently undertaken. Speaking valve in situ. Pt 2 person assist with slide sheet with bed mobility and not currently ambulant. Nil complaints of dizziness pain or shortness of breath. T: Assist physiotherapist with placing the patient on tilt table for treatment to improve WB through long bones and stimulating sensation of stand. A: The patient was transferred from the bed to the tilt table via slide sheet with 2 person assist. The patient’s blood pressure was taken at supine and interval levels of elevation on the tilt table. the patient’s blood pressure slightly dropped at ~ 45 degrees but then increased to 120/80. The patient was then elevated to ~85 degrees with blood pressure stable. Reaching to the left and right was then commenced. R: The patient managed for ~ 3min and then became unresponsive, clammy, gurgling and stiff. Blood pressure and oxygen levels were taken. Saturation levels were 97% RA via trache however blood pressure was ~96/58. The patient was immediately lowered to ~45 degrees and tracheostomy cuff was reinflated. The patient became responsive after ~5seconds. E: It is unclear what happened to the patient during this treatment session as the patient had previously managed well on the tilt table two times previously that week with no significant changes in blood pressure. The patient stated feeling fine when becoming responsive nil complaints from the patient. S: I turned to the physiotherapist for action during the incident and then enquired about what the procedure would be in that instance to initiate a MET call. The incident was clearly documented and I would know how to manage a situation in future from the advice and action of the physiotherapist.

Initial Entry

2011-03-27T02:24:00.000-07:00

My second rotation in the neurosurgery ward. My initial thoughts are a bit apprehensive and nervous about this placement as it is a large hospital as well as the fact that neuro requires a lot of theoretical knowledge. I’m unsure as to my role as a 4th year in a neurosurgery setting. I have gathered from feedback that the caseload will be around 5 or 6 patients a day. However, I’m not sure about the level of independence we will have as neuro is quite a complex area and I would think there would be an adequate level of supervision. My major concerns about the placement will be identifying impairments and treatment strategies individual to the patient as I will need to be able to respond quickly to the patient particularly if there are any behavioural or cognitive issues involved. I also think that this placement will be quite confronting as I have not had much exposure to neurosurgery patients in particular. I think that I will have an extended time with patients as opposed to my last placement which was quite quick as there were numerous patients to be seen. I think that my assessment skills and treatment skills will be refined and challenged as each patient will react differently depending on the level of injury. I am hoping that this placement will be a good learning curve, interesting as well as challenging but at a manageable level for my capability as a student.

Final Entry

2011-03-20T05:26:00.000-07:00

After 5 weeks in a rural acute hospital setting, I feel I have gained a vast experience in a variety of presenting conditions. I initially focused on studying orthopaedic cases, however I soon realised that an acute ward, particularly in a rural area contains a variety of cases.
I was able to gain experience clinically on the ward with a combined case load including cardio, neuro and orthopaedic patients. I also gained some experience in musculoskeletal in an outpatient setting.

By the end of the placement, I was able to run the ward and delegate the patient load and plans for the day. This became challenging towards the end of the week as the case load almost tripled with new admissions, theatre admissions, and current patients. I was able to further develop my skills in prioritisation of a case load and time management skills.

Throughout the placement, I developed the confidence to approach multi-disciplinary team members and provide opinions from a physiotherapy perspective and aid in discharge planning. This is something that I found difficult in my previous placement and I was able to overcome this challenge. I also developed some musculoskeletal outpatient skills but I did not have a lot of time allocated to this area and this will need to be consolidated in my musculoskeletal focused placement.

Overall, this placement was the most beneficial I’ve had to date as it allowed me to be in an acute hospital setting, see a variety of presentations, enabled me to work closely with multidisciplinary team members and become more confident and independent with applying my skills. Although I am still not confident with particular presentations such as ICU, I feel this placement has prepared me well for the next three this year and has provided a foundation as to the field of work I may eventually end up in the near future.

Week 5

2011-03-20T04:58:00.000-07:00

S: 88-year-old male who suffered an AMI 3/52 ago and did not seek medical attention. The patient then collapsed twice since the infarct and was admitted. Patient cares for his elderly wife and received services to assist with her care. Patient is NFR and had been in bed 2/7 since admission.

T: To perform a subjective and mobility assessment on the patient, mobilise the patient and determine any other relevant requirements the patient may have needed such as walking aids and additional services.

A: I initially performed a subjective assessment. On assessment, I discovered the SpO2 levels had not been obtained. The patient was unable to provide a full subjective history secondary to drowsiness. I did not perform a mobility assessment.

R: I was able to obtain some subjective information from the patient. However, I did not perform a mobility assessment or attempt to mobilise the patient, as I was uncomfortable with the medical stability of the patient.

E: Although I was unable to gain the information, I required for the patient, I feel I made the right decision in choosing not to mobilise the patient. Without knowing the O2 saturation levels and lowered level of alertness of the patient, I did not feel it was safe to attempt to mobilise the patient particularly as the patient was NFR.

S: Strategies I used was to seek advice from my supervisor after the subjective history and presenting the situation and my action to not perform the assessment. I liaised with the medical team regarding my concerns for the patient and this was acknowledged.

Week Three

2011-03-07T06:08:00.000-08:00

S: 52-year-old male inpatient referred for physio due to desaturation of oxygen following abdominal surgery. The patient had been a smoker for 20 years and recently quit. The patient’s current saturation levels were 95% on 3L of oxygen.

T: Assess the patient’s cardio respiratory function including a subjective history and perform the relevant treatment for the findings.

A: I performed a routine subjective history particularly relating to the patient’s cardio respiratory function. I asked questions about cough, sputum production, smoking history, and what was normal for the patient. I ausculatated and took the patients room air sats. I then taught the patient breathing exercises and a supportive cough.

R: The patient had decreased breath sounds but no evidence of crackles or wheeze. The patient’s saturation levels on room air were 93%. After ambulation, this dropped to 89% but was relieved with deep breathing and a cough and soon returned to 95%. The patient reported feeling better after ambulating.

E: I think my overall assessment and treatment for the patient was done reasonably well. I was a bit worried about the drop in saturation levels after ambulation, however they increased with intervention, which I was relieved about.

S: I did not seek any advice from my supervisor however; next time I could have employed a walking exercise programme for the patient to do with monitoring of sats to determine any levels of improvement in saturation levels with ambulation. This could have been then carried over into a home exercise programme for the patient.

Week One

2011-02-20T00:13:00.000-08:00

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.

4th Year Initial Entry

2011-02-11T21:52:00.001-08:00

It is my first rotation for my 4th year placements and first rural. I am quite nervous because I have never been away from home before, and I don’t have the luxury of going home to family and friends after a hard day’s work.

After last year’s placement, I feel more confident and comfortable in dealing with patients and carrying out assessments and treatments. However, I know the level of expectation for 4th year is higher than 3rd year, so that makes me a bit nervous as there is a lot more responsibility placed upon us.

I think it should be a fulfilling and educational placement. I’ve never been on a general surgery ward or done outpatients before so it will be a good chance to experience both aspects as I want to go into musculoskeletal physiotherapy after graduation.

Overall, this placement should be a great preparation for what is to come throughout the rest of the year as well as what the work will be like once we become qualified. I think I will have a hard time the first few days trying to adapt to being away from home as well as the hospital environment. I’m hoping that by the end of the placement I have mastered my time management as that was an issue on my last placement.

I hope overall my communication skills, professionalism and hands on skills as a physiotherapist will become strengthened so that I can become more confident and successful in my future placements and my career.

Final Entry

2010-08-27T02:59:00.000-07:00

After a hectic five week placement, I have definitely learnt a lot. The placement was a lot more than I anticipated and I was quite overwhelmed particularly within the first week. However, by third week I was more comfortable and adapted to the environment as this was the first clinical placement I had at a hospital.

I was given my own patient case load and became the primary physiotherapist for these patients as opposed to taking more of a therapy assistant role. As a result of my hands on experience, I became more aware of patient needs and was able to build my communication skills as the weeks progressed which allowed me to develop a greater rapport with my patients.

My communication skills also developed as I participated in multidisciplinary team meetings and was able to provide input to patients and become involved with discharge planning.

I learnt how to perform ortho-geriatric initial assessments effectively and safely, as well as implement treatment plans for patients based upon initial assessment. My documentation skills also improved as I began documenting my assessments and treatments in a formal manner.

I found that I had an issue with time management and found it difficult to organize my patient load as my plans never carried through, and I learnt to deal with adjusting them.

Overall, it was a good educational experience, particularly as I had never been in a hospital environment before and I was unsure what to expect. I learnt a lot about different treatment ideas, how to manage patients (particularly when they refuse physio), and how to liaise with other multidisciplinary team members.

Week Five

2010-08-27T02:35:00.000-07:00

S: This week I was presented with a 74 yr old female with a right dynamic hip screw 13/8 after a #NOF following a mechanical fall. The patient had a history of CVA, dysphasia, dementia, and a previous left hip and right knee replacement.

T: My task was to perform an initial assessment on the patient as she arrived to the ward

A: I gathered all the required information for the subjective from the patient notes and proceeded with my subjective history. I then proceeded to perform an initial mobility review as well as an overall upper and lower limb strength and range assessment.

R: I was able to gain an idea of the patient’s history but not exactly how the fall happened due to the patient’s dysphasia and dementia. The upper limb range and strength were within normal limits. The patient’s right lower limb strength and range was less than the right, which was expected post op.

E: I found it very confronting to try and perform an initial subjective history on a patient with dysphasia and dementia. It was difficult for me to gain a rapport with the patient and find out details as the patient became very frustrated due to the dysphasia. I was able to complete the assessment but found it challenging.

S: I was able to establish through my initial assessment that the patient responded well to one stage commands during my assessment and employed these clear, simple commands throughout the remainder of my treatment sessions.

Week 3

2010-08-17T03:31:00.000-07:00

S: This week I was given an 82 yr old female who presented with chronic bilateral back pain whilst hanging out the washing and upon examination it was found that the patient had bilateral pelvic fractures but with no history of falls. The patient had a history of cardiac failure and a failed L TKR which resulted in a fixed knee extension deformity. The patient also had a complex medical history of diabetes, anxiety and depression, low motivation, and was reluctant to participate in physio.

T: My task this week was to carry out a treatment session based on my initial assessment, which included improving the patient’s balance and ambulation

A: I had to use my communication skills to encourage the patient to participate in the physio session and explain the benefits of it. I explained that changes will take some time and tried to motivate the patient. Once I got the patient’s consent, I continued to encourage and reassure the patient during the session as she became very anxious and apprehensive.

R: The result of my communication to the patient enabled patient consent to physio and to participate in the session

E: Although I was able to gain consent from the patient, the physio session was not as productive as the patients apprehension and anxiety proved to be a large barrier towards treatment.

S: I was able to ask my supervisor for advice on how to manage a patient with low compliance and apprehension and employ these to encourage the patient.

Week One

2010-08-02T03:39:00.000-07:00

S: This week I was given a 90 yr old male patient with a history of CRF and two AV replacements that needed rehabilitation after deconditioning as he had been hospitalised for the last 2 months. He was able to walk approximately 10m with a wheeled zimmer frame with one standby assist before fatigue.

T: My task was to perform an initial assessment of his mobility, muscle strength, muscle ROM, and balance in order to begin a treatment plan.

A: I performed the relevant assessments required using outcome measures to qualify my assessments. I used the Oxford scale for muscle strength, measure relevant muscle ranges with a goniometer and performed the Berg Balance Scale as an assessment for balance. To also assessed his static and dynamic sitting and standing balance and ambulation.

R: After carrying out these assessments, the patient received at least 3/5 for each relevant muscle regarding muscle strength, and a Berg Balance Scale of 40/56 indicative of a falls risk. He was safe in his static and dynamic sitting and standing balance

E: The main issue I had carrying out the initial assessment was during my Berg Balance testing. I found it difficult to ensure I was able to perform the assessment safely, and in particular, the latter parts of the assessment such as picking an object off the floor and reaching forward.

S: I asked my supervisor for assistance during those later parts of the Berg Balance assessment to ensure the safety of the patient and myself. I also was able to find out the best positions to place my body to ensure the assessment was safe and practice these throughout the week to build my confidence in performing the assessment and make sure I was being safe.

Initial Entry

2010-07-23T23:33:00.000-07:00

Its time for my second clinical placement and I am more anxious than I was last year as I am going to be placed at Kaleeya Hospital whereas last year I was at a private practice. It will be interesting to see how physiotherapy is run in a hospital setting as this is new to me. I expect this placement to be educational as well as reinforce my prior knowledge of geriatrics.

I am hopeful that as a third year, I will able to be more interactive and hands on with the patients, which will allow me to strengthen my communication skills, professionalism and technical skills. I am hoping that I will be seeing some of the same patients throughout my placement, which will allow me to see potential growth and recovery, allowing my placement to become a more rewarding experience.

I am doing 8:00am to 4:30pm, which I am very happy about, as my hours on my last placement were longer. As a third year physiotherapy student, I expect to either be watching the superior physiotherapist with hands on experience or, if I am lucky, I may be given my own patients.

My placement last year was not as fulfilling as I expected as I didn’t really get much hands on experience, which was disappointing. Thus, I am a bit concerned that the level of expectation required of me at Kaleeya Hospital as a third year physiotherapy student may be greater than my abilities at this stage. I still feel like a second year going into a third year placement which may reflect during the initial weeks. However, I am positive and I am a fast learner so I will be able to adjust to the expectations and provide physiotherapy to the best of my abilities.

Overall, I’m excited to be in a hospital setting and am hoping for a rewarding, challenging and educational second placement.

Final Entry

2009-11-20T04:04:00.001-08:00

It’s been five long weeks and clinical placement has come to an end. My initial beliefs and ideas going to a private practice were fairly negative as I was concerned with the level of hands on application I would be able to apply. These issues were certainly evident throughout my placement. I was only able to apply limited hands on skills, which were primarily ultrasound and massage, which are fairly basic. I was hoping to apply passive accessory and physiological mobilisations, as opposed to basic EPA and massage techniques. However, I was able to refine my massage technique throughout the placement.

I also watched patients being treated by the physios most of the time, which after 8 hours, everyday for five weeks, can be quite tedious. I was, after mid assessment, allowed to perform a total of three subjective histories, one on a post accident, which actually resulted in fracture so physio wasn’t applicable, one pre-op knee and one post-op knee. I really enjoyed doing those as I felt like a real physio, rather than a student just watching.

The other main issue I came across was the fact that most patients presented with either back or neck pain, which we haven’t covered as second years, so I was limited in what I was able to do subjectively as well as hands on. I also felt confused watching treatments, as I didn’t understand the kinematics of the treatment techniques, despite my attempts. That was probably the most disappointing aspect about my placement.

I did however, gain a lot of insight in terms of communication with different types of patients, as I was able to communicate with them and gauge an understanding of their journey and how physio has benefited their lives. I also learnt a lot about total knee replacements, particularly post op, as I saw them frequently throughout my placement. I also learned a lot on exercise prescription as the facility had a gym and exercise classes, which was really good to get involved with.

I think the main thing I gained from placement was the exposure and experience. I got to engage with patients about their experiences, which provided me with a lot of insight. I also learned a lot on exercise prescription, as well as to be more confident and assertive in my approach. As I wasn’t really able to apply many musculoskeletal mobilisation techniques, I did refine my massage skills. Overall, it was a good experience, but there was a lack of hands on application, which was disappointing.

Week Five

2009-11-20T03:34:00.000-08:00

Situation: I was given the opportunity to witness an Ilizarov frame on a 37-year-old male who sustained a complex comminuted fracture to his tibia and fibula following a motorcycle accident 6 weeks prior. The Ilizarov frame was being used for fixation of the tibia and fibula until he underwent a bone graft. He had the frame for 4 weeks and it was being removed within the next week.

Task: I mainly watched and maintained professional behaviour during the treatment, but I was also allowed to apply ankle mobilisations to increase ankle range of motion and reduce stiffness

Action: I performed ankle mobilisations to the joint. However, as I performed the mobilisations, my hand was hitting the frame, as well as some pin sites beginning to bleed and seep fluid. I had to sit down in the treatment room after my supervisor took over in order to gain my composure as I was feeling nauseas and overwhelmed from the appearance of the frame and the pin sites

Result: There was ultimately greater range of motion at the joint, and I maintained my composure throughout the remainder of the session.

Evaluation: I felt I maintained professional behaviour during the session despite feeling overwhelmed and somewhat disgusted by the bleeding of the pin sites. I was able to remain professional particularly on first seeing the frame as I was shocked, but I remained composed. I also could’ve excused myself from the room if I couldn’t handle it, but I don’t feel it reached that level, as I felt fine within a few minutes.

Strategies: I feel I employed strategies to maintain an adequate level of professional behaviour during the session and was able to successfully apply treatment techniques in a professional manner despite feeling overwhelmed by the appearance of the frame, as opposed to the task. After witnessing the frame, I feel I am more prepared to see similar forms of fixation without feeling as overwhelmed.

Week Three

2009-11-08T03:09:00.000-08:00

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.

Week One

2009-10-25T00:58:00.000-07:00

Situation: This week, I was given the opportunity to participate in a physio session of an 18-year-old male patient with recent left minor patellar dislocation. This session was one of a few follow up physio treatments from a prior initial assessment. He presented with recurring anterolateral knee pain as well as increasing posterior knee pain. This was preventing him from returning to work as an apprentice carpenter, and was important that the condition was addressed to allow him to return to work as well as ADL’s.

Task: The main priority of this physio session was to manage the presenting condition to alleviate pain, facilitate healing and promote normal functioning and movement, which would enable him to return to work.

Action: I initially measured his knee flexion and extension to use as a baseline assessment. I then used ultrasound on the anterolateral aspect of his left knee to relieve pain and promote healing as well as massage on his hamstrings to relieve muscle tension as this could have been contributing to his recently acquired posterior knee pain.

Result: After using ultrasound and massage, the patient reported a decrease in pain levels from a 4/10 to 2/10, and was able to gain further range of motion after treatment when compared to his knee flexion and extension at the beginning of the physio session.

Evaluation: The main issue I had was my technique whilst using the ultrasound. As the anterolateral aspect of the knee was quite bony, the ultrasound head was losing contact with the knee and therefore affecting the efficacy and primarily the use of the treatment. There were times during treatment where the contact of the ultrasound head was adequate, but there were more times where contact wasn’t. I need to develop and practice my technique in the future in order to improve the intervention.

Strategies: I continued to practice the use of ultrasound throughout the week with different areas of the body such as the neck in order to improve my technique. I was able to seek advice on ways to improve my application and found I need to employ different strategies such as applying slightly more pressure on the head of the ultrasound as well as using slower circular motions. I used these skills in other sessions and was able to improve on my overall treatment technique.

Initial Entry

2009-10-14T23:25:00.001-07:00

I’ve waited two years and the time has finally arrived for my first clinical placement. I am definitely excited and anxious to see what it is truly like to be a physio, see real patients with real conditions, and hopefully witness treatment success and client satisfaction.

I’m going to a private practice musculoskeletal clinic in Mandurah. My first thoughts when I found out it was a private practice were primarily disappointing as I’ll probably be limited in my hands on application of skills and treatment as there are insurance issues associated with students. However, I do like the fact that it’s a musculoskeletal private practice, as I feel most knowledgeable and comfortable in this area of physio.

Nonetheless, after taking the time to think about my true expectations for clinical placement, I realised that although I may be limited in hands on treatment, I’m still going to be able to gain exposure to different musculoskeletal disorders in a real clinical setting. I think the exposure to the clinical environment, liasing with colleagues and experiencing what its like to be a real physio will hopefully be a beneficial and rewarding experience. I’m confident in my communication and musculoskeletal clinical skills, so I’m hoping my first placement will be a positive and successful one.

I’m not sure how the day will be structured. I am working Monday to Friday, 8a.m to 5p.m with an hour for lunch, which I'm sure I will be using to research different conditions and treatment techniques. I know there is a hydrotherapy pool and exercise gym and I will be able to participate in hydrotherapy at some stage during my placement. I’m assuming my day will consist of some physio, some hydro sessions, and some non-contact time, which I’ll either be researching, or doing marketing and promotion for the clinic.

As the student in the facility, I’m not sure what my role will be exactly as it is a private practice and there may be some concerns with how much handling and treatment I'm able to do. I’m hoping that at minimum I will be able to sit in on physiotherapy sessions and participate in hydrotherapy sessions to have a first hand account on professionalism, subjective history taking in a clinical setting and treatment.

My only concern at this stage would be what is expected of me as a second year physio student in a private practice. I’m hoping I’ll be able to get as much exposure and hands on experience as I can, in order to gain the most benefit from the experience. I’m definitely anxious and nervous about starting, but I’m sure once the first week is over, I will feel like a real physio.