Rotation 1 Fourth Year - Assessment STARES

Situation
A 71 year old woman was referred to the Outpatient Department at Armadale Hospital by her GP with a diagnosis of tibialis posterior tendonitis and medial malleolar zone pain. This was after an accident at the supermarket where another woman ran into her ankle with a shopping trolley 4 months earlier. An x-ray had ruled out fractures as a possible cause of her pain, and an ultrasound had found some degeneration in both the medial and lateral malleolar zones as well as marked swelling.

Task
I was asked in the referral letter to assess and treat her accordingly.

Action
Wanting to be prepared for the patient and have all of the possible causes of her pain fresh in my mind, I read up on medial ankle pathologies and the possible differential diagnoses of these. I assumed that while the diagnosis may not be correct the GP would have at least correctly described the area of pain. However, when the patient arrived I quickly found that her pain was not in her medial ankle but instead in her lateral ankle. All of the pathologies and tests I had revised were no longer relevant to this patient. I quickly rethought my approach to my objective assessment to include structures in the lateral ankle such as the ATFL, deltoid ligament and CFL and did my best to bring on the patients symptoms. However, no matter what I tried, whether it be a functional test, muscle strength test, muscle length test or ligament integrity test I could not bring on her pain except in weight bearing activities. Even in the weight bearing activities she could not pin point the part of the activity that aggravated it except that it was when her weight went through her ankle. I was becoming thoroughly frustrated and nervous as my supervisor was present and offering no solutions to me. After taking too long to complete my objective assessment the patient announced that she had to return home straight away as she was a carer for her disabled husband. My supervisor spoke up and said that it was ok to rebook and continue the assessment later that week if the patient is happy with that. Luckily the patient was very understanding and was happy to come back a few days later.

Result
My actions eventuated in a patient leaving the department with no diagnosis or understanding of her problem and no treatment was given. If it were another patient they could have been very unsatisfied with the length of time I had spent with them without any resolution to their problem. However, I was lucky enough to have a very understanding patient who did return to the department to continue their treatment.

Evaluation
Of all of the bad experiences I have had on a placement this would have to be the one that I am most ashamed of. I feel I completely let down my patient, offering them no explanation or solution to their problem. I believe that I let myself assume what was wrong with the patient before they even arrived. Not by believing the referral as it was exactly, but by believing the referral at all! She is not the only patient who has arrived with completely different sore body parts than the ones spoken about in the referral. This is not only because of the GPs but also because of the length of waiting time that is unavoidable in the public system and some pain symptoms can change in a matter of months. I also believe that I didn’t take the patient’s chronicity and non irritability into account and was not aggressive enough to bring on the patients symptoms. Whilst part of me does wish that the supervisor had stepped in at the time, I feel that he didn’t want to embarrass or undermine me in front of the patient and we later had a lengthy discussion about the patient regarding what I could have done to avoid the situation and how to approach the patient the next time I saw her. Whilst I believe that the situation was terrible and one I never want to repeat I believe the discussion and therefore the things I have learnt from the situation would not have come about without making the mistakes that I did. I am also glad that I kept my cool in front of the patient and never let her know that I was concerned and frustrated. To her it just appeared I was doing my job and ran out of time.

Strategies
I believe that my objective assessment was not dynamic and flexible enough, as I had already made assumptions about what was wrong with the patient before I had seen them. All areas of assessment and treatment should be always changing depending on each new piece of information the patient presents to me. I should never stop at the end of the objective assessment and start thinking about what is wrong with the patient, I should be already forming ideas as I go so that I can change my assessment if need be. Also, my objective assessment was not aggressive enough for a patient that was non irritable and chronic. A patient like her requires an aggressive assessment to find the source of the symptoms. Through the week I practiced my objective assessment on the ankle and when the patient returned later that week I was a lot more aggressive, dynamic and flexible with my assessment. Unfortunately I still couldn’t find the source of symptoms but my supervisor and I discussed it and decided that there may no longer be an injury, hence no reproduction of symptoms, but that the pain is centrally mediated. Whilst it would have been nice to find a source of symptoms, I can safely say that I performed an effective objective assessment and that my findings were accurate the second time around.