week 1 post- assessment (prac 2)

S: A 48 year old female patient presented to the outpatients clinic 3 months post- TKR for ongoing rehabilitation. The patient had been referred from her doctor for rehab and also due to her reporting high levels of pain in the knee despite still taking a strong form of pain relief. On observation, her knee was still very swollen (although this is common post- operatively) and judging by the patients facial expressions, walking into the treatment area was very painful. My clinical tutor was present during the assessment.
T: Conduct a thorough (initial) subjective assessment to discover possible mechanical (or non-mechanical) reasons for her pain levels.
A:I conducted a full subjective assessment with the patient (including past medical history, social history... and so on). In particular, I focused on determining aggravating/easing factors as well as twenty-four behaviour of the pain and enquired about the history of the presenting complaint (i.e. pre-op function and post-op progress).
R: By the end of the subjective I gained further insight into possible causes of her pain and was able to reassure and educate the patient based on what I had found. Possible causes included the fact that she was trying to do too much daily such as doing the lawn mowing and other strenuous activties around the house. The exercises that she had been given post-operatively also had not been progressed greatly over the past 3 months and I felt that if they had her knee would have been able to cope with more strain that it currently is. The patient had also not been using many strategies to ease the pain apart from taking analgesia. On observation during my assessment, I noticed the patient was wearing flat hard-soled thongs. I found that the patient had a lot of questions related to prognosis and was concerned that she was not where she should be in terms of her function and pain 3 months post-operatively.
E: I thought I managed to ask key points under each of the 'subjective headings' and used open ended questions to obtain as much information as I could and also to get an idea of her main concerns and what she thinks about the pain experience. I think I was a good active listener and enabled the patient to feel empowered. I observed the patient right from the minute she walked in and throughout the subjective interview which I believe helped contribute to me getting a good picture of the patients presentation. For example, as mentioned I noticed that she was wearing shoes that did not provide much support for the knee which could potentially be a contributing factor to her pain. I determined some distinct aggravating factors however I did not explore these as much as I should have. I needed to establish clearer time frames i.e. how long the pain took to come on with a certain activity, how long it took to ease and what the intensity of the pain was like with each activity. In doing this I could have gotten a better idea of the behaviour of her pain as well as how irritable her presentation was. This could then be used as a baseline measure to assess if her pain is improving on subsequent physiotherapy sessions.
S: In order to improve on this as the placement goes on, I need to continue asking open ended questions however also guide the patient a little more to obtain information that is meaningful to me in order to assist in my clinical reasoning. I need to establish more specific details under certain parts of the subjective, for example, by asking questions based on my theoretical knowledge and narrowing the open ended questions into more specific ones. In this case, finding out about time frames associated with the onset of pain, etc would be very useful to look back on to assess whether there is any progress with regards to her pain. Also, if I have a better understanding of a patient's pain I can educate and reassure them for effectively and with more confidence.