The Big Physio Survey - Example of Clinical 3

Keywords

peer support, reflection, experience, MSK, clinical reason

Who or what is my case report based on?

This case report is based on a patient who I saw as a second opinion within one of the community clinics in which I am based. The patient is male and aged 28 years old. I have been qualified for 11 years and have worked as an ESP within this time so I am available to see patient's within our service who more junior members of staff think may benefit from a further assessment.

What is the physiotherapy event or episode of care?

My colleague asked if I could reassess this patient. They had previously seen him and was unsure of both the diagnosis and if the patient should be referred on for further investigations.

What were the aims of the physiotherapy event or episode of care?

The aims were to subjectively and objectively reassess this patient and formulate a management plan for his care. Dependent upon the outcomes of the session the aim would then be to communicate this plan with both the referrer and the patient.

What did I do?

I completed a subjective and objective assessment with the patient, including specific questions and performing tests which may indicate specific wrist pathology that may need further investigations. I applied my clinical reasoning skills to differentially diagnose the condition. I then communicated this to the patient, the referring staff and the intermediate care team.

What was the outcome or effect?

As a result of the assessment findings, I referred this patient onto an intermediate MSK team detailing my reasoning and explaining why I was referring them on, explaining why imaging may be beneficial and change this patients management and what I thought the probable diagnosis was.

Why did I do this?

Assessment findings indicated that it was likely that this patient had a diagnosis that warranted further imaging. Referring the patient on would result in the patient being seen in the right place as soon as possible. Communicating the referral effectively addresses my objectives and also enables me to highlight any possible patient expectations and perceptions. Discussing this case with the more junior member of Physio staff enables me to clinically reason my management and also further their knowledge regarding why this patient was referred on and how their assessment skills may be improved in reflection. Hopefully this experience also had a positive outcome for the patient, which is something that is very important.