S-approximately 40 year old female. Presented with neck pain and LBP with symptoms in her left leg extending down to her foot (P & N, etc). She also complained of altered sensation in her left upper limb.
T-I did a very thorough subjective assessment to rule out any red flags and followed with an objective to assess whether her symptoms in her arm were related to her neck pain. Aim was to treat both neck and back pain in that session.
A-I spoke to my supervisor before continuing as I found after the assessment she had almost 4 or 5 red flags, possibly indicating cancer or a neurological source. I did not end up treating the patient however my supervisor did some treatment. We referred the patient to the doctor to be assessed.
R/E-As mentioned previously I did not treat the patient but in telling my supervisor what I had found the patient can be cleared of anything more serious and we can continue to treat her without needed to take any precautions, etc . I think it was good that I picked up that something may not have been quite right. My weakness was that I tried to write a referral letter and it could have been summarized a lot better.
S- I think I could practice writing referral letters so I can communicate better with other health professionals.
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