Last week I had a new patient coming in with a shoulder problem (RC pathology and possible impingement).
It took me 2.5 hrs to complete subjective and objective examination and to provide her with some treatment. I was very frustrated, and almost lost my patience.
The reason it took me so long was not because it was a very complicated problem in itself but the fact that the patient answered all my questions very vaguely and she could not cut a story short.
As I wanted to be specific in my assessment and trying to find out exactly when her pain would increase during movement and what it felt like I found my self becoming very angry at the person for not being able to answer a simple question with yes or no. I tried every possible way of asking questions trying to minimize the possible answers but then she would just not answer it but would describe her sensation in her shoulder in one way but then say: Oh, but if I do it again, it feels different.
Now, how can I be specific and chose the most appropriate treatment option if a patient is unable to be just a tiny bit specific in her description?
I decided to treat the signs that I was able to measure objectively, which is decreased GH caudad and AP glides and weak scapular stabilizing muscles. I will not even attempt to ask about subjective asterisks in the next session as it would probably take half of the treatment session to assess these. All I will ask is: has there been a change since the last treatment? And hope for a yes or no answer...
2 comments:
Hi Edith, I know exactly what you mean, when the patient keeps changing the story as you go along and you can’t get a precise picture and come up with the best treatment option.
During my last musculoskeletal prac I had a patient who had a multiple pains in his body, he was depressed and was on works compensation for 15 years. He also hated all the medical staff. So as you can imagine what an attitude he had when I started doing my subjective assessment, he thought I was asking all those questions because I didn’t believe that he had pain. His answers were much generalised as well, even though I tried to be as specific as I could.
Anyway my suggestion to you would be go with what makes sense to you with a patients presenting complain and with the objective findings that you found. I guess with more experience we will be able to handle those patients better in getting the answers that will help us with diagnosis and the best treatment option.
Hi Edith, that sounded very frustrating and upsetting- particularly if you fear that you could be criticised by your supervisor (were you able to discuss it helpfully with your supervisor afterwards?)I had some problems with my rotator cuff recently and I havent yet been to a physio- one of the reasons I didn't go was I didn't want to give a useless subjective history-pain position and quality varied so much. I think you were sensible to decide to track the objective signs -I tend to ask with such a patient just a simple -"in one sentence is your overall shoulder pain the same worse or better" -mine is better by the way overall (: doing lower traps, discontinuing UL weights for the moment, and getting trigger point releases (from husband) on infraspinatus. Basically my experience as a patient and with treating stroke shoulders (spent ages tracking subjective in one pt I remember- I concentrate more now on causes of alignment issues and treat these) is that shoulder pain is often difficult for patients to be simple about and keeping in mind the general localisation of referred pain vs non referred pain helps.
All the best with this patient,we all are challenged at times by chatty imprecise patients
Steph
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