recently two of my pts in a hospital outpt setting were discharged by their consultants with the plan to 'continue with physio management'. The problem for my supervisor and i was that we were not achieving gains with physio (the pts had platued for a number of reasons) and we were considering sending them back to the consultant for review of their condition as it was becoming apparent that interventions other than physio might be needed. The consultants, however, seemed to 'get in first' and handball / discharge them to physio for continued management, stating that there was nothing further they were able to do for the pt.
What happens in this situation when both parties decide they are unable to appropriately manage the pt and feel other involvement is needed?? with one pt i wrote a letter to the consultant (with the guidance of my supervisor) stating the reasons we thought he needed a follow up and why discharging him to physio was inappropriate. My supervisor dealt with the other pt as it was an ongoing issue. Has anyone else come across this situation in a hospital setting where different departments refer pts back and forth? Is there a 'higher power' in this type of situation that decide whats best for the pt? or do the departments need to compromise and come to an agreement on a course of treatment?
Tuesday, 25 September 2007
distracting visitors
Has anyone needed to ask family or visitors to leave a treatment session? i was treating a 22yo pt who presented with knee instability and occasional sharp pain. She was fitting her physio sessions in amongst uni lectures and one time arrived with 2 friends. They walked into the treatment rooms with her and in doing so said 'oh its ok that my friends come in isnt it??' to which i said that was fine so long as they allowed us to focus on the physio session. During assessment they were all talking and i politely asked if they could leave the chat till later as we had limited treatment time. During HLB Ax they were laughing and distracting the pt and thus affecting the outcome, and again i asked that they please sit quietly while the session continued. This happened a couple more times throughout the session and whilst i found it easy to ask them to be quiet and not distract the pt i felt unable to ask them to leave, seeing as id already said they could come in. Has anyone else asked people to leave? What is the best way to go about it?
Tuesday, 18 September 2007
Conversion disorders
While on my neurology placement I came across approx 4 patients with a ‘conversion disorder’ otherwise known as Hysterical neurosis. Apparently that it is post grad stuff but I found it very interesting. For those of you who are unsure here are some facts:
- essentially a conversion disorder is when psychological symptoms manifest as physical symptoms (although there is no evidence of organic cause of the symptoms)
- It is a psychiatric condition
- Common signs and symptoms may include paralysis in an arm or leg, difficulties swallowing, sudden blindness/deafness, or nonepileptic seizures
- Symptoms usually appear suddenly and may follow a stressful experience
- Conversion disorder is rare
- affects women more than men
- most commonly people between age 10 and 35 years of age
Case study: One of my patients who was only young had been assaulted and had presented to the hospital with L sided weakness. The doctors did all the CT/MRI scans and found no organic cause of his weakness and so gave him the dx of a conversion disorder secondary to the stress of the assault. Initially I found it really hard to get my head around this diagnosis as his symptoms were very real i.e. he was unable to stand on his L leg with out it collapsing and shaking like mad. But then when my CCT saw him, the first thing she said was that he had a conversion disorder- just by looking at him. I guess looking back, that his presentation didn’t really fit. He would
- hop on his right leg to get around- which is very strange as it takes a lot of strength in both legs to hop
- he had 2-3 falls (which apparently is a sign of conversion)
- he had pain the whole way down his (L) side which was not dermatomal and had no apparent cause
- when testing sensation and proprioception his results were inconsistent and it appeared as though he was trying to get them wrong
I guess essentially we need to be mindful of this condition and that it exists. Even though it is rare (I saw 4 patients on 4 weeks with it…)
- essentially a conversion disorder is when psychological symptoms manifest as physical symptoms (although there is no evidence of organic cause of the symptoms)
- It is a psychiatric condition
- Common signs and symptoms may include paralysis in an arm or leg, difficulties swallowing, sudden blindness/deafness, or nonepileptic seizures
- Symptoms usually appear suddenly and may follow a stressful experience
- Conversion disorder is rare
- affects women more than men
- most commonly people between age 10 and 35 years of age
Case study: One of my patients who was only young had been assaulted and had presented to the hospital with L sided weakness. The doctors did all the CT/MRI scans and found no organic cause of his weakness and so gave him the dx of a conversion disorder secondary to the stress of the assault. Initially I found it really hard to get my head around this diagnosis as his symptoms were very real i.e. he was unable to stand on his L leg with out it collapsing and shaking like mad. But then when my CCT saw him, the first thing she said was that he had a conversion disorder- just by looking at him. I guess looking back, that his presentation didn’t really fit. He would
- hop on his right leg to get around- which is very strange as it takes a lot of strength in both legs to hop
- he had 2-3 falls (which apparently is a sign of conversion)
- he had pain the whole way down his (L) side which was not dermatomal and had no apparent cause
- when testing sensation and proprioception his results were inconsistent and it appeared as though he was trying to get them wrong
I guess essentially we need to be mindful of this condition and that it exists. Even though it is rare (I saw 4 patients on 4 weeks with it…)
Monday, 17 September 2007
Hi all,
My second post of this week:
Subarachnoid Haemorrhage (SAH)
1) Diagnosis:
- Full Neurological examination
- Ongoing neurological observation (E.g. GCS)
- CT Scan
i. Confirm the diagnosis in 95% of causes
ii. Blood may be widely distributed or more localized
iii. Can also identify other conditions such as hydrocephalus and ICH
- Cerebral Angiogram
i. Undertake by all patients
ii. Four vessel angiography
- Lumbar Puncture
i. Presence of blood in CSF is a positive result
ii. Patient has LP done needs to RIB at least 6 hours
- TCD’s
i. Measure the velocity of blood flow in intracranial vessels
ii. A reading of 120cm/s is significant
2) Things need to consider when seeing patients who has SDH on ward
i. Make sure you know what type of surgery the patient had done, E.g.) If
patient had a craniectomy, they are not allowed to sit up without a helmet
ii. No driving or RTW for at least 6 weeks (For discharge planning)
iii. Fatigue can be a problem for some months post bleed (Impact on your clinical
decision)
iv. Always ask your patient whether they have any dizziness; you need to know
whether the dizziness is position related or movement related. From my 4
weeks experience, it is not uncommon for patient to have some forms of
vestibular impairments.
My second post of this week:
Subarachnoid Haemorrhage (SAH)
1) Diagnosis:
- Full Neurological examination
- Ongoing neurological observation (E.g. GCS)
- CT Scan
i. Confirm the diagnosis in 95% of causes
ii. Blood may be widely distributed or more localized
iii. Can also identify other conditions such as hydrocephalus and ICH
- Cerebral Angiogram
i. Undertake by all patients
ii. Four vessel angiography
- Lumbar Puncture
i. Presence of blood in CSF is a positive result
ii. Patient has LP done needs to RIB at least 6 hours
- TCD’s
i. Measure the velocity of blood flow in intracranial vessels
ii. A reading of 120cm/s is significant
2) Things need to consider when seeing patients who has SDH on ward
i. Make sure you know what type of surgery the patient had done, E.g.) If
patient had a craniectomy, they are not allowed to sit up without a helmet
ii. No driving or RTW for at least 6 weeks (For discharge planning)
iii. Fatigue can be a problem for some months post bleed (Impact on your clinical
decision)
iv. Always ask your patient whether they have any dizziness; you need to know
whether the dizziness is position related or movement related. From my 4
weeks experience, it is not uncommon for patient to have some forms of
vestibular impairments.
Base of Skull Fracture
Hi All,
I am going to share with you some knowledge which I have learnt for the last four weeks in neurosurgery ward. They are as follows:
Base of Skull (BOS) Fracture
1) Most common clinical features are blood or CSF from ear or nose
2) Those patient with CSF leakage may complain of a salty tasting fluid running down the back of throat
3) Patient has BOS fracture with CSF leak is far more severe and potentially life threatening when compare to patient who only has BOS fracture
4) Two main complications for BOS fracture with CSF leak are:
- Cerebral Infection ( Particular bacterial meningitis)
- Pneumocephalus( Accumulation of air in cranium)
5) Medical Management:
- BOS fracture with not CSF leak is managed conservatively
- If a feeding tube is required, an orogastirc tube is used instead of nasogastric tube.Nasogastric tube is not used due to the risk of increased trauma to the region
- For surgical repair, it involves a frontal lobe craniotomy with repair of the dural defect using a fascia lata graft
6) Physiotherapy Management:
- Consult neurosurgical registrar before mobilizing
- Many of these patients will have vestibular problem due to the proximity of the BOS fracture to the VIII cranial nerve.
- If patient has vertigo on ambulation, he/she may need stemetil (medication) regularly
7) Respiratory Care
- All suction should be performed via the guedels airway or via an endotracheal tube or trachyeostomy. This will avoid further trauma to the region and minimise the risk of infection
I am going to share with you some knowledge which I have learnt for the last four weeks in neurosurgery ward. They are as follows:
Base of Skull (BOS) Fracture
1) Most common clinical features are blood or CSF from ear or nose
2) Those patient with CSF leakage may complain of a salty tasting fluid running down the back of throat
3) Patient has BOS fracture with CSF leak is far more severe and potentially life threatening when compare to patient who only has BOS fracture
4) Two main complications for BOS fracture with CSF leak are:
- Cerebral Infection ( Particular bacterial meningitis)
- Pneumocephalus( Accumulation of air in cranium)
5) Medical Management:
- BOS fracture with not CSF leak is managed conservatively
- If a feeding tube is required, an orogastirc tube is used instead of nasogastric tube.Nasogastric tube is not used due to the risk of increased trauma to the region
- For surgical repair, it involves a frontal lobe craniotomy with repair of the dural defect using a fascia lata graft
6) Physiotherapy Management:
- Consult neurosurgical registrar before mobilizing
- Many of these patients will have vestibular problem due to the proximity of the BOS fracture to the VIII cranial nerve.
- If patient has vertigo on ambulation, he/she may need stemetil (medication) regularly
7) Respiratory Care
- All suction should be performed via the guedels airway or via an endotracheal tube or trachyeostomy. This will avoid further trauma to the region and minimise the risk of infection
Sunday, 16 September 2007
relaxation : not just for the hippies
Hi All,
I had been working with patients who suffers from dypsnea the last 4 weeks. I have used relaxation techniques on many occassions. Some patients are a little bit uncomfortable with this 'new age' thing, some are willing to try anything that works.
One of my patients was an anxious lady who was diagnosed with Type 2 Resp. Failure (recovering) with a past medical history of Breast Cancer (in remission), she also suffered hip and groin pain when actively flexing her hip. I taught her breathing control combined with relaxation technique because of her dyspnoea. No one could figure out or dwell into too much why she's anxious. I guess after we all have been working in the medical respiratory ward for a while, we just assume the dypsnoea's to do with respiratory diseases. The day before her discharge, she revealed to me that she's been worrying about the cancer cells might have spread to her hip as that's what happened to her sister who died to similar cause. She then told me that she used the relaxation breathing technique to help coping with her anxiety related dyspnoea when she was in the scanning machine and that it will be her daily practice from now on. (She's been cleared from cancer, by the way. It was a false alarm.)
I have learned two things from this:
1. it takes time to piece together the cause of dyspnoea sometimes, it's not always so straight forward, anxiety may be the cause, but what is the cause of the anxiety, that's the part we need to have some patience to figure it out.
2. relaxation technique works on ppl who are receptive to it.
I had been working with patients who suffers from dypsnea the last 4 weeks. I have used relaxation techniques on many occassions. Some patients are a little bit uncomfortable with this 'new age' thing, some are willing to try anything that works.
One of my patients was an anxious lady who was diagnosed with Type 2 Resp. Failure (recovering) with a past medical history of Breast Cancer (in remission), she also suffered hip and groin pain when actively flexing her hip. I taught her breathing control combined with relaxation technique because of her dyspnoea. No one could figure out or dwell into too much why she's anxious. I guess after we all have been working in the medical respiratory ward for a while, we just assume the dypsnoea's to do with respiratory diseases. The day before her discharge, she revealed to me that she's been worrying about the cancer cells might have spread to her hip as that's what happened to her sister who died to similar cause. She then told me that she used the relaxation breathing technique to help coping with her anxiety related dyspnoea when she was in the scanning machine and that it will be her daily practice from now on. (She's been cleared from cancer, by the way. It was a false alarm.)
I have learned two things from this:
1. it takes time to piece together the cause of dyspnoea sometimes, it's not always so straight forward, anxiety may be the cause, but what is the cause of the anxiety, that's the part we need to have some patience to figure it out.
2. relaxation technique works on ppl who are receptive to it.
Saturday, 15 September 2007
Global overview
I had a pt this week who presented with no pain but the last three years after an annual sports carnival she gets quad pain. So she came to me to see what she could do to prevent it from happening again and the carnival was the next day. How do you treat no pain? In this situation PMH is important she had a hx of sprained ankles and knee ligament damage on the same side. This suggested that she had instability problem on that side which also is the side of her quad injuries. So i tested her SIJ which showed massive instability and subsequently had lead to her ankle, knee and quad problems. So when stumped take a step back and view the whole picture.
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