Depressed geriatric pt

This blog concerns a patient I saw whilst on my gerontology placement. I was set to see her with my Curtin supervisor and demonstrate a thorough geriatric assessment. Upon reading the patient notes, I found that this lady had become a widow earlier that year and since then had become less mobile and less motivated and had increased her alcohol consumption significantly. The medical staff had noted that she was suffering from depression and this was very evident in speaking to her. When I entered the room, the patient obviously didn't want to see anyone (commenting "and what are you going to make me do?") and in my initial questioning I was able to gather that she was in quite low spirits. I spent most of the first session talking to her as I felt it was important to develop a good rapport with the patient if I were to get her to do anything and the only intervention we did was a short walk before she needed to sit down due to dizziness and fatigue.

My Supervisor commented afterward that it would have been more effective to do little questioning and get the patient up and going for a more effective session. I felt, however, that had I done this the patient may have found me pushy and, in my opinion, it would have been less likely that i would have gained cooperation in future treatment sessions.

In future sessions, I found myself getting the patient to do a little bit more every day and her making great progress, as well as developing a great rapport. In contrast, most of the other staff found her difficult. 

I learnt from this situation that sometimes it can be effective to allow the patient a little more time to tell you their background and not be too pushy in order to have a good treatment outcome. Having said this, I will keep in mind that not all patients have the luxury of a longer stay in the hospital and sometimes you will need to get them up and going straight away. some patients may also use your not so "pushy" nature to their advantage...a few things to think about I guess.

This blog concerns my cardio placement which was undertaken in ICU. A fellow student and I were to assess a patient who had been in the ward for at least 10 days. We read his History etc and went into his room. He was in his late 20’s and had been the victim of a punch which knocked him out. He was ‘coming around’ every so often lately so we were asked if we could perform a subjective and objective assessment on him.
On entering his room we were met by some members of his family. After introductions and reasons for being here were explained to all they willingly left so we could perform our duties. A nurse was in the room and she was performing her duties but we were ok to commence.
We started our subjective assessment. I was the first to ask him questions. And I was met with silence and a blank stare. After a few more tries I suggested to the other student (who was a female and the patient was a male) that she try the subjective questions. She got a slightly better response so we went with her asking the questions. He wasn’t very willing to engage with us overall. We persisted as best as we could and after 20 minutes the nurse was informed that we were finished. She went out into the waiting room and got the patient’s family to bring them back in. Just before we were going to leave his room he appeared more responsive and happy. I put this down to his family being back there with him. Just before we left he held his hand up to me as if to say thank you. I acknowledged this and told him we would be back to see him again at another time.
This perhaps indicated to me that sometimes it may pay to have someone who the patient is comfortable with in the room. This may help them engage or if required a family member can ask the questions on your behalf. I guess asking the nursing staff prior to seeing a patient like this can give you an indication of what kind of communication strategy you should use and more importantly if anyone should be in attendance to make it easier for all concerned!

Sorry, this isn't working out!

Whilst on my country prac I was treating a patient in the outpatient department who was suffering from a sprained ankle. She had sustained this injury a year ago and she was convinced that she had fractured the medial aspect of it. The x-rays indicated no fracture! She also had a referral for a lower back complaint. Over the coming weeks she would improve at one stage and then come back in 3 days later and report 9/10 pain. Yes I went through the pain scale with her, explained it etc. She didn’t look like she was experiencing 9/10 pain. Anyway amongst her other medical history it was written that she suffered from fibromyalgia. Could this explain her high levels of pain?
The senior physio was a gun and knew her stuff. She came in to the last few appointments I had with this patient because it was getting confusing and not following the script I would have thought it should. The senior suggested one day we look at the patient’s lower back. The assessment I carried out and treatment was performed accordingly. The senior and I would see her in 2 days time. She came back worse off. I had no idea what to do with this lady and the senior was ‘stumped ‘ also. We gave her 2 more appointments before the senior decided to refer this patient on. She explained to the patient that maybe she needed to go back to her GP as PT intervention was not helping her condition. It was actually quite a ‘release’ to hear someone say that especially the senior because I regarded her as a very good physio, she had at least 10 years in the profession and she had taught me quite a lot during my time there. The patient agreed with this course of action.
This act taught me a lot. If PT intervention is not helping a patient then there is no point wasting anyone’s time and more importantly delaying some further investigations which may need to take place.

Don't believe the truth!

This blog concerns my gerontology placement. A patient had come in one afternoon (suffering from a UTI) and I was to see her with my Curtin Clinical Tutor. The patient was from a high level care nursing home. According to the notes the patient ambulated with a WZF. Fine! When the tutor and I went into her room she had nurses working with her and we probably wouldn’t be able to see her today. Ok, I could do my mobility assessment tomorrow I thought, no dramas.
My tutor suggested I ring the nursing home just to clarify some of the information from the admission notes regarding the patient’s current ambulatory status. I obliged but thought why was I doing this. I put it down to the fact she just wanted to hear me communicate to another health care professional over the phone.
I called the nursing home and spoke to a physio there. She explained to me that this patient does not ambulate at all! She gets around in a wheelchair. I told her about the admission form we had. What had happened it was explained to me was this lady in her confusion had got up from her wheel chair in the dining room grabbed someone’s WZF and proceeded to walk with it. Interesting I thought.
I got off the phone and relayed this to my tutor and a nurse who was aware of us following this up. I guess I was the most surprised that that could happen. A valuable lesson was learnt and I know if I ever have any doubts about some information I read regarding a patient I will follow it up. Or if it concerns our job such as mobility status then it doesn’t hurt to clarify a few things!

Scary Injuries

I encountered a very scary injury while I was working as a sports trainer this year, and wanted to share it. I worked with a rugby team this year and the worst injury that could happen on a rugby field nearly did. During an U20's game the scrum collapsed and the hooker injured his neck, a very scary suspected spinal cord injury.

I immediately placed a neck brace on him, log rolled him onto a stretcher and took him off the field. During class, studying spinal cord injuries you always imagine what you would do, but when its in front of you its very different. While on the side of the field I subjectively checked if the patient had any pins and needles, change in sensation, headache or muscle strength changes. Objectively i checked his sensation and when that was all normal I gently and isometrically tested his muscle strength. The results from all the tests above were within normal limits, but he was complaining of a painful neck. I then allowed him to sit up with the neck brace on and continued to monitor him for the next 30min. After this time he had no further symptoms, besides the neck pain. At this stage I removed the neck brace and treated his neck cautiously, but as a musculoskeletal injury.

I was quite freaked out after this incident. So when I was on my musculoskeletal clinic I discussed my treatment of the injury with my supervisor. Our ideas of how we would manage this condition were very similar. The most important thing i learnt from this case was to always communicate with your patient. Let them know what is going on at all times, and let the patient know that they have to keep you informed if they begin to develop any neurological symptoms. I hope none of you have to ever be in this situation, but if you ever are I hope this helps you.

Patient Exposure

While on my neuro placement I treated an Abouriginal patient from a rural community near Broome. I learnt a lot about communication and cultural differences from this patient. I learnt from my own mistakes and from the mistakes of others.

While on the ward he was considered a falls risk and had a permanent male nurses aid in his room. This nurses aid in particular was very forceful man, and often said quite derogatory comments towards my patient. At one stage I was assisting the patient to transfer from his bed and into the wheelchair to go to the physio gym. This nurses aid seemed to take over from me and demand that the patient move. He was very reluctant to move!

I noticed a few moments later that the patient kept on adjusting his pants, he was scared that he might be exposed in front of me. It was at this point that I tactfully told the nurses assistant that his assistance was not neccessary and for him to stop. Just by allowing the patient to regain his composure and give him back his dignity made the rest of the treatment session flow well.

This incident made me quite angry, I couldn't believe that someone could be so disrespectful to another person. I learnt so much from this incident, that when a patient feels volnerable they wont want to partake in any form of therapy and knowing when to intervene in a professional manner to prevent this happening in the future.

Postnatal Depression -Scary reality

On my rural placement I treated a patient with a very confusing musculoskeletal issue. She was referred to the local hospital for abdominal, ?C-section pain. When she arrived, her abdominal pain was not her most serious complaint. When filling in her body diagram, it seemed to nearly be completed coloured in. She complained of headaches, neck pain, lower back pain, thigh pain, knee pain and pain on the soles of her feet when walking.

Not only did she have a complicated pain picture, but her social history raised a few yellow flags too. She lives with her husband and 2 children, one 2 years old and the 3 months. She recently moved to the area and has no family support. She brought her baby in with her, the baby was constantly crying and this seemed to make the patient very distressed.

To be able to perform the objective assessment, my supervisor took the baby out of the room. This seemed to slightly calm the mother, but when the baby returned she needed to be fed. Unfortunately the baby was unable to be settled and the mother decided to leave very quickly without making a follow up appointment. Everything seemed to happen very quickly, I felt out of control in the situation.

My supervisor and I immediately discussed this case. We felt that because she had not made a follow up appointment at the time that we needed to refer her back to her GP immediately. From her presentation we both felt that she could be suffering from postnatal depression and required further help.

Unfortunately I was unable to see this patient again during my placement. If I was able to see her again, I would have liked to book a double appointment and given us more time to spend on each issue and not feel rushed. If she was able to get a babysitter for her daughter during the session that would be great, but in the circumstances I don't think this would have been feasible. In a case like this I feel that building a good rapport with your patient and gaining their trust would be the most important factor in treating their musculoskeletal problems. I wish I had been able to see this patient again, but despite that I feel that I have learnt a lot from this case.