Situation: Day 2 at a musculoskeletal outpatients clinic. This day is usually
set aside for new patient triage but I have a 9:30 patient booked in from
previous student physiotherapist. First triage patients arrive at 8:30 and I
believe this is enough time for me to get an initial assessment completed prior
to my 9:30 appointment. As I approach the reception desk to accept the patient
file, the university tutor arrives and agrees to go through the patient with
me. I am then handed the file of a 63-year-old woman with lower left sided back
pain extending into her left hip and down her leg. She has had x-rays and is
awaiting an MRI of her spine. On further investigation into the medical notes,
the lady has had a long history of abdominal pathologies including ectopic pregnancies
and bowel disturbances with pain. She is 10-year post breast cancer, which is
why the MRI has been ordered.
Task: Conduct an initial assessment to investigate the left lumbar pain
and the associated leg pain.
Action: I discussed the case with my tutor and reviewed the x-ray images of
her spine and hips. I then proceeded to the waiting room for introductions and
escort the patient through to the treatment area. The patient was obviously
walking with an antalgic posture but was otherwise appeared to be in good
health. I introduced my tutor and started gong through the initial assessment
form. The knowledge of the previous episode of cancer and the patient’s age was
dominating in the back of my mind to make sure my triage was correct and this
patient was suitable for physiotherapy. Within the first few questions the
patient stated that she was waiting for the MRI and was unsure why she was at
physiotherapy. I explained that different forms of assessment can give a
potential diagnosis and that at this point all avenues were being investigated.
I found myself starting to be lost in the initial assessment form and not
thoroughly covering all the questions. By the time I began some objective tests
my supervisor entered to tell me my 9:30 appointment had arrived. I became a
little flustered as I was unsure of what my options were at this point. My
supervisor said he would see my booked patient, with a small smile that did not
go unnoticed. The subtext screamed “TIME MANAGEMENT” and “PLAN AHEAD”. I made a
mental note to reflect on later as I realized I had not been watching the clock
at all and had been totally focused on my patient. I continued with my
objective assessment observing posture and functional movements. Although the
referral from ED had made the pain sound like lumbar spine nerve compression,
the presentation at the clinic appeared more like knee pathology/injury.
Investigation of the spine/hip/SIJ and ankle did not recreate the pain but knee
flexion and extension bought on the pains. It was agreed that the patient may
have some knee pathology that required further investigation. The MRI on her
spine would still go ahead but we would rebook her for the following week to
further investigate and treat the left knee as a possible source of her
symptoms.
Result: The outcome was that I was able to conduct an initial assessment on
a patient with obvious red flags and still consider them a good candidate for
physiotherapy.
Evaluation: I felt I performed well in the situation. My tutor was helpful
although an unexpected guest. Having another person present evaluating my
performance always heightens my performance anxiety (OSCA style), but I found
that on this occasion I was able to focus on the patient and was happy to have
an experienced physiotherapist helping me out with a potentially more sensitive
subject. The tutor was very respectful of my process, even when I started to
fall in a hole. This allowed me to find strategies to stay on course even with
some obvious blunders (time management and missing some important explanations
of the special questions to the patient). I did not shine on the time
management front which would have been noted by my supervisor.
Strategies: Watch the clock. If a patient is booked within two hours of a
triage day (hopefully this time will reduce with practice), request only
straight forward patients. If an unexpected event arises, like a tutor turning
up, take charge and re-evaluate your day and identify time constraints. It
would have been the perfect opportunity to show the supervisor that I could
effectively time-manage and utilize other team members. If being an independent
practitioner is the goal, I cannot afford to make these mistakes. It is not
what would be expected of a professional.
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