Week 3: Communication

Situation:
Patient A immigrated from Egypt four months ago. She lives alone with her husband in a single storey house. Patient A was referred to the outpatient clinic for reveiw and management of her left shoulder pain after two recent falls. One fall involved a bus door closing on her and the other "tripping over the kurb on the road." Patient A had recent x rays indicating no fractures and an ultrasound in which bursal inflamation, a supraspinatus tear and biceps tendon thickening were detected. Patient A was accompanied by her husband.

Task
To complete a thorough subjective assessement in which i would need a detailed pain chart, the history of the incident, any relevent previous injuries, a social history and a thorough medical screening. Before commencing my objective assessement my supervisor requested that i come and discuss my findings with him and inform him of my intended approach for my objective assessement.

Actions
I chose to start with the history of the incident. this required me to ask detailed questions about both falls. I not only required the details of the mechanism of the fall, but also the management of the injuries immediately after the incident. After i was satisfied with this history i progressed on to the body chart. I started with the left shoulder and then allowed my patient to inform me of the other aches and pains she was experiencing associated with the falls. From the pain chart i went into a social history. I asked about my patients current living situation, employement, hobbies and daily activities. After i had attempted to get a medical history, i informed my patient that i was going to speak with my supervisor and that i would return to continue the assessement very shortly.

Results:
From the start of my subjective assessement i knew that the language barrier was going to interfere with me retrieving the information i required to make an accurate diagnosis. With the assistance of body language and a lot of questioning i was able to obtain a clear history of both falls. The first real problem i encountered was on the body chart. My patient seemed extremely eager to inform me of all her aches and pains. It was however very difficult to distinguish which pain came from which fall. My patient had difficulty describing the nature of the pain. She did not understnad words such as ache, pulling, dull or sharp. With the assistance of her hands and facial expressions i was able to assume the difference between the three main pains that she was experiencing. Patient A also had difficulty describing the aggravating factors. She appeared to have difficulty conveying which activity brought each different pain on. All of the pains seemed to blur into one. Patient A gave me a very brief social history, in which she revealled she did not work but had been studying english at tafe untill recently. She did not reveal any hobbies and her daily activities consisted only of housework and an occasional visit to the shops. I had a lot of difficulty getting a medical history of my patient as she did not understand any medical terminology. My discussion with my supervisor took longer than expected. When i returned to the room to continue my assessement 15 minutes later, my patient had left and was sitting back in the waiting room with an angry husband. I apologised for the wait and after gaining consent again, directed my patient and her husband back into the treatment room.

Evaluation:
This patient was particularly challenging as i not only had a cultural barrier but also a communication barrier. When i was asking questions for my body chart i needed to make it clear that we would discuss one pain at a time. I feel this directed approach would give me more accuracy in my assessement and more detail of each different pain. As my patient was new in the country and was unfamiliar with australian culture and lifestyle i feel i should have probed into my patient's social, cultural and religious background a bit more. I feel this would enable me to engage with my patient and give me a better understanding of their 'pain' experience.The next thing i need to monitor is the explanations and instructions i give to my patients. My patient's husband decided that she should leave the treatment room as the session was completed. As i later discovered, in muslim culture the husband is the authoritive figure. Therefore i needed to explain to the husband who was waiting outside, that i was going to speak with my supervisor and that i would return to continue.

Strategies:
1: I need to identify that there is a language barrier early in the assessement and organise for an interpreter to sit in on the session and assist with the communication
2: I need to do do a more thorough social history to engage with my patient. In this case i had no understanding of their culture, religion or way of life. This information is crucial for me to gain trust from my patient and design an appropriate home exercise program for their lifestyle.
3: I need to be more specific with my body chart and work chronologically through each pain, rather than discussing them all at once.