Topic One - Assessment

Sunday February 14, 2010
Situation: On the Thursday afternoon of my first week of placement I was at the Augusta clinic location for the second time (I also go to Augusta hospital and the Margaret River clinic). At this stage of the week the vast majority of clients that I had seen were follow-up cases who were returning for more treatment. I had watched my supervisor perform a couple of initial assessments to get a feel of how he goes about it but I had performed no more than half a dozen myself. A young male presented at the clinic with his mother and a referral from his GP. The referral from the GP had no diagnosis, only that the young man was to be assessed by a physiotherapist in regard to an injury sustained to the left lower leg in a basketball match the previous evening. He ambulated into my assessment room on 2 axillary crutches, non-weight bearing on his left leg and using a step-through gait.
Task: It was my task to take a subjective history and perform an appropriate physical/objective examination on the client so as to ascertain what I thought the young man’s problem was before discussing treatment possibilities with my supervisor if deemed appropriate. My supervisor was present for advice and back-up if I required it.
Action: I began my task by informing the client and his mother that I would have to ask a series of questions, so ensured that they were comfortable before the process began. I was completing the body chart and found that the boy’s pain was on the posterior aspect of his left calf at the location where another player had made contact with him. I completed the remainder of the body chart and continued on with the rest of the subjective history. When I had finished the subjective history I turned to my supervisor to see if he had any further questions to ask before I began an objective examination. His response was that I had done well, but I needed to ask if there were any other pains/problems because I had neglected to ask this when I was doing the body chart. With this instruction, I asked the boy if he did indeed have any other pains beside the one we had just run through on the back of his calf. He reported that he didn’t really think much of it, but he did have some pain around his general left hip region. After checking that he didn’t have any additional pains (which he didn’t) I directed my focus to the left hip pain and followed through with all my subjective questioning on this pain.
Result: After completing the subjective history in its entirety it turned out that the left hip pain wasn’t the most intense pain but was the more limiting and was actually a large part of why the young man didn’t feel confident weight bearing through his left leg and so was using the crutches. A very thorough objective examination of the lumbar spine, hip, knee and ankle revealed that the posterior calf pain was most likely just tenderness and inflammation from the contact made by the other basketball player. While the hip pain my supervisor and I concluded was a result of the angle of the contact which came from the other player and had caused an awkward distraction-like movement of the leg from the hip upon impact. There wasn’t marked instability around the hip, but it was certainly very painful for the boy, so I applied some ultrasound because of the acute stage of the injury and provided education about the Rest, Ice, Compression, Elevation (RICE) principle for both the hip and calf. The client was given a home exercise program of stretches and advised to return for further treatment if the problem had not resolved by the beginning of the next week.
Evaluation: I felt my performance in this situation was poor and I was very disappointed in myself for missing the secondary hip pain if it hadn’t of been for my supervisor. I must have had a lapse in concentration to skip such a vital part of the assessment and something which I definitely should have known how to do, being the body chart of the subjective assessment. Despite my self dissatisfaction, I am glad that I made this error when my supervisor was present and that it was at an early stage of my placement, because I know now that I have made such a simple mistake that I will never make it again. After the client and his mother had left I had another discussion with my supervisor and he explained that you must be very thorough with your subjective history and that he is particularly meticulous with the body chart because you don’t want to complete a whole session worth of treatment to end and find out that there are other, possibly more important pains that you need to address. He also told me not to get too down on myself because the rest of my performance was good, which was comforting when I reflected on the situation.
Strategies: I think that the obvious strategy here is that there is no substitute for a good quality subjective assessment because it really serves to guide you through your objective and that to do this; you need to know how to properly perform a subjective assessment. After this mistake, I revised in detail my history taking notes on Thursday evening and made sure I performed top quality examinations on Friday, which my supervisor complemented me on too, which was satisfying. The other strategy that I took out of this experience is to utilise my supervisors throughout the year as much as possible, because they are the ones who can identify problems with any of my skills and help me to rectify them so that mistakes and errors aren’t made in the future. A third point that I took from this experience is that you cannot take any referrals as being 100% factual and you should always conduct your own assessment of the person sitting in front of you before you decide to start treating them.