During the first week of my musculo placement, I had a new patient booked in with a referral for a condition which I thought would be quite easy to treat so I wasn’t too worried. However, when the patient came in, I discovered during the subjective that it was not just a simple condition; she had multiple areas of pain, none of which pointed to the condition stated on the referral. I freaked out a bit because I had no idea what to focus on because all the pains were related and I wasn’t sure what the cause was. It took me a long time to so my subjective as I had to go through every pain and ask for a VAS score etc. I went a talked to my supervisor after both my subjective and objective and due to the fact that I had freaked out a bit I missed a few important things in my assessment that would have made the situation a bit clearer. However, with my supervisors help the problem was deciphered and was actually quite simple.
When working in the musculoskeletal area, there is no doubt that all of us will come across patient situations like this. More often than not patients do have multiple areas of pain, as students, we have our supervisors there to help us work through what the most important areas are to treat, and also in this case which area may be causing all the other pains. However when we get out into the big wide world, we’ll have to make these clinical judgements on our own. In my limited experience, I’ve found that one of the easiest ways to do this is to simply ask the patient which area is causing them the most problems and focus on that as in reality we may only have 20 minutes to treat in. The other important thing is to complete a really thorough subjective and objective and this will make a big difference to your clinical decisions.
Since seeing this patient in my first week, I’ve been trying to not go into any patient consultation with preconceived ideas of how the patient is going to present, because chances are it may be completely different to what you were thinking. With this mindset, I feel that I’m less likely to freak out when a patient who I thought would be uncomplicated turns out to be quite complex.
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2 comments:
It can be daunting to have a patient with a body chart completely coloured in! I have had similar instances and taken the same approach as you. I also let them know that I am not ignoring their other pains, just prioritising them according to which ones the patient finds the most severe.
I think that this situation is a very common one, i had a patient who had the entire (R) side of her back coloured in! In these cases you're totally right-a good subjective exam is crucial, and can make the difference when diagnosing and deciding where/what to treat first! Prioritising as ryan said, is probably the best way to go, as is making sure you have good communication with your patient-and good rapport with your patient definitely helps. If the patient understands your reasoning behind your chosen treatment then it makes everything much easier.
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