week 1

ASSESSMENT
S:
Today patient a presented with R shoulder pain. Pt a was referred from the orthopaedic department with a complex past medical hx of lung ca, COPD, left and right shoulder pain and back pain.

T:
My task was to complete a thorough initial assessment, subjective and objective.

A:
I found my subjective assessment difficult to conduct. My patient was very talkative and tended to jump in-between relevant information and other associated stories. My objective assessment involved a full assessment of the shoulder. I assessed ROM, Impingement, instability and Rotator cuff function.

R:
I felt that in transferring the pt's story to the page i may have missed information. I did not have the patients medical file on me so when my patient began to discuss different investigations he had in the past, I found myself confused and unable to follow clearly. At the end of my objective assessment i did not have enough information or a clear clinical picture so i needed to go back and retest/explore different movements and positions to further investigate the source of pain and its nature of dysfunction.

E:
I found this initial assessment to be the most challenging so far. The patient did not fit into any clinical pattern that I was familiar with. I feel my weakness in this session was definitely my lack of structure.

S:
I need to use more closed questions in my subjective assessment to keep my patient focussed. I also feel my objective assessment needs more depth. I need to really explore each area of the assessment before i move onto the next test so i can draw links between my findings and gain a better clinical picture. For example i needed to explore passive shpoulder flexion in both an internally rotated position and an externally rotated position in order to gain the required information.