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Jacque Hemler
During my first day at clinic, I was able to see a patient who had undergone multiple surgeries due to buccal cancer. This was an interesting case to me because I haven’t encountered a cancer patient before in the clinic. The patient had recently undergone surgery where they took part of the inferior border of the scapula to replace part of her mandible due to the cancer spreading to bone. They also took a skin graft from her back to place over her cheek where the mandible was rebuilt. The pt had reported having a headache when we first got there, so my CI performed a suboccipital release which helped relieve some tension. Next we got to do some scar mobilization on the skin graft on her cheek and the scar on her neck from the exploratory surgery. Next we did some exercises for her shoulder to help gain back some ROM due to the surgery from removing part of the scapula and skin. We also did some strengthening of the quads, hip abductors, and glutes from her general weakness after having to go through chemotherapy. I liked how we were able to focus on multiple parts of the body, not just one specific area. We plan on continuing to strengthen her legs and working on mobilizing her scar tissue.
Mary Davern
The patient was a 38 year old WM who was severely overweight despite having lost 280lb over the last two years. He had difficulty ambulating and required a walker. His cardiovascular endurance was poor but he displayed a moderate amount of strength in the upper extremities. He had arthritis, lymphedema in both legs and a large lobule on this right leg with considerable knee pain. I felt a little overwhelmed because he was so big. Every part of his treatment required more forethought. If we wanted to use a piece of equipment, we had to make sure he would fit around it. We used a pulse ox to check his HR and oxygen levels after each set of exercises to ensure that his vitals stayed within normal ranges, We also asked him to report how he was feeling using an RPE chart. My CI asked me to think of new exercises to add to his program. The main goal was simple: to improve overall strength and cardiovascular capacity. However I found it difficult to come up with exercises that he could manage but were still sufficiently challenging. We did a lot of seated exercises with weights and seated dynamic exercises with a medicine ball. I was really impressed with his levels of motivation. He had lost his job due to his weight and has a full time caregiver at the age of 38 but he was turning his life around. I could tell he had been working hard lose weight and was continuing to do so. He took breaks but always completed the exercise without any complaints. I also thought my CI handled the situation beautifully. She was encouraging but not overly peppy. The patient felt totally comfortable and trusted her. Next time, we plan on transitioning to standing exercises using the cable machine and decreasing his rest time so his heart rate stays elevated for longer periods of time to increase his cardiovascular endurance.
Austin Wernecke-Home Health setting
Evaluation of new patient. Pt is a white female of 59 years old, undergoing chemo treatment as well as two years out of a right hemispheric stroke. Upon talking to the patient, observing how she sat, her attitude and body cues, I was confused as to why she was in home health and not outpatient. She seemed strong and strong-willed. I felt optimistic that she would advance in treatment quickly. Upon testing her muscular endurance, 2-minute walk, and standing march test, my mind changed. The pt’s left leg would get weaker and give way early on in the 2-minute walk test, as well as she had to take breaks during the march test. Seeing that she was much weaker than I thought. In conclusion, I am wondering if this is stemming from her stroke since her left is weaker, and is now resurfacing with her fatigue from chemo. The plan is to administer general strengthening and endurance exercises and using a cane with ambulation. Exercises include marching while standing and single leg standing.Alex Gett
pt is 58 yo female c/o lumbar pain and bilateral anterior hip pain. Pt reports the pain is worst when she takes her first few steps after being seated for long periods of time; she has a desk job. Pt reports pain as aching and localized to the regions mentioned. Upon standing/walking observation, it was noted that pt has bilateral genu valgum, slight kyphotic posture of t spine, and decreased lumbar extension. I was thinking OA due to pt demographic, gait observation, and her chart, but after talking to the pt, her symptoms were not severe enough to justify my original thought. My CI has been treating this pt for a few weeks, so I did not get to see a detailed exam performed on her. My CI informed me that he believes both illiopsoas mm are the culprit and he has been working on calming them down through repetitive standing lumbar extensions, movement in prone, and lumbar mobs. Upon ambulation reassessment, pt had a more rhythmic gait and reported her pain went from a 3 upon arrival to a 0 by the end of her session. PT informed her to continue HEP. I’ve seen the psoas mm act as the culprit for lumbar pain in the past, so I am not surprised here. I’m glad I got to see hip pain on my first day since we are working on that unit in MSK.
MJ Erskine
I’m following my CI, PG, through the rehab gym at a SNF and I notice someone who may be trying to get his attention. I get his attention and we detour to ask what she needs. She softly says, “my oxygen isn’t working.” ! After replacing the tank, making sure that the lines were fine and that the nasal cannula was placed properly, and trying multiple fingers because the pulse ox wasn’t getting a reading, the O2 reading was 99. She was reassured, another therapist was nearby, and we went on our way.
Later, we saw her as our 2nd to last patient. We found her slumped forward in a long sit position on the bed. Each time PG spoke to her to get her attention and start PT, she gave a nonsensical but audible response. He spoke loudly, tapped her on the shoulder and still got the same lack of response. Off we went to check with the nurse, who, understanding us to say that the patient was unresponsive, jumped out of her chair and raced off. Upon all of us entering her room and the nurse speaking to her, the patient, woke up.
I’m thrilled that everything went well. I even got to do her exercises with her, though I was perhaps overly cautious. But after thinking and writing about this, I realize maybe I should ask a few more questions about worst-case scenarios the next time I converse with my CI.
Rachel Lenz
My CI and I were working with a lumbar fusion patient within the hospital, trying to get her to stand and walk to the chair. She would then stay there for an hour or so before going back to the bed. She was very anxious about walking and creating more pain by moving. We allowed her to take her time, as she was in pain while sitting on the side of the bed, but we tried to make her understand that standing would most likely be less painful then her current position. Once in the chair she was sweating, nauseous, blood pressure had dropped, and pulse was very fast. Luckily she did not throw up and we were able to stabilize her and make her comfortable in the chair. The encounter made me very nervous and I did not want a pt to throw up on me the first day of clinic. The good part was that I stayed calm the whole time. The not so good is that I was at a loss of how to handle the situation, so I needed to be told what to do every step. I think that if I was not so overwhelmed by the patient’s status, I would have been able to better anticipate what should have been done. We could have taken her BP prior to standing and left it on her arm so that it could have been evaluated while standing or directly after sitting down. The next time I encounter this, I will suggest putting the BP cuff on prior to standing and I will be more prepared on how to help decrease the pt. anxiety that created the situation.
Sabrina Harbaugh
My first day at clinic was relatively straight forward. We encountered numerous fracture patients, both upper and lower extremity, along with a handful of joint replacement patients. I was impressed to see that the therex portion of the patients treatment sessions were very individualized, however the biggest struggle I am current facing would be how to broach the ultra-sound discussion. Although we have not covered modalities officially in PT school, I have learned modalities through PTA school, the AT program and continuing education and I personally have found the research to be lacking, significantly. I also realize that my CI has YEARS of experience that is making them a fantastic clinician and that prior to heavy emphasis on researched based practice that modalities were thought to be a great help to our patients, thus I do not believe it is “just utilized for extra billing” but rather a lack of updated information/justification for our interventions that is causing the continued use of this modality.
Given this perspective that I formed over the years, I am looking for feedback on discussing the use of ultra-sound on 80% of patient case load.
Peter Cradduck
In an in-patient setting I learned from a patient in “memory care”. It was our first patient of the day. The 72 y/o male patient was in a wheel chair. PMH included OA, Parkinson’s, DM and dementia. The kyphotic man far the most complex case I’ve ever seen on paper. His Parkinson’s only manifested itself by making his movements slow, no tremors or inability to initiate movement. This man’s cognitive levels seemed to be rather keen despite his diagnosis, he demonstrated the ability to follow verbal commands and keep count. He was oriented and aware and his demeanor was cheerful. The man had severe contractures in his hamstrings that were a result of years in a wheelchair. His trunk flexion was severely limited which inhibited his ability to stand on his own volition. My CI made it clear that it was not out of the question for him to be able to be more mobile independently despite his comorbidities, this was a surprising revelation. What I learned most from this first experience in a dementia ward, was that creativity was essential to the process of physical therapy in this setting. It occurred to me that perhaps with lengthened/stretched hamstrings and increased trunk flexion, this individual would be able to stand and transfer by his self. He was able to stand while holding on to the railing for nearly two minutes by his self before his bent arthritic knees gave up and he sat back down. This creativity in care is not like the creativity found in the OP setting. It is my goal to recognize potential impairments and become a more creative therapist in order to assist in the mobility of those that have already lost so much.
Samantha Schambach
Today was the first day of clinic and also my first day in an inpatient acute care setting. I was nervous to be in an environment that I had not been before, but was ready and willing to take on any challenges that came my way. For the most part it was a easy day as my CI was planning on showing me the ropes before throwing me to the wolves, so to speak.
One patient did stand out to me though. I had the opportunity to work with an 89 y.o. WF who had severe dementia. The goal was to get her up and out of bed so we could assess the appropriate discharge planning. I was not sure what to expect as I have heard many stories about people with dementia or Alzheimer’s not being the most friendly people to work with, which is understandable as they can become frightened. My intention was to let the PT handle the conversation and I would be there where ever she needed, as to many people talking can get very confusing for the patient. I was surprised to see that this patient was non-verbal and very calm upon arrival. She was willingly to do what the PT asked, but did not understand commands fully, especially when asked to stand. After some brainstorming on how we could get this patient up and walking we decided to put the walker in front of her and see if there would be an automatic response to get up. She seemed to do better with the walker as we got her to lift her bottom off the bed, but still was not understanding our requests and therefore would not put pressure through her feet.
Next time we suggested having visual cues for the patient, like having a chair in sight so she can see where she is going and might have motivation, or take a small portion of the fear away as she can see the end plan in sight. I think we had some good strategies that we used that day that we can build upon for future experiences. Although being in the acute care setting, we may not get to see this patient again, I will be able to use this experience to know better for the next patient that comes along.
Jesse Parsons
The patient was a 20 y.o. Hispanic female with back pain in two locations. Her pain was in her upper trap/suprascapular area on the left and the right, as well as in her lumbar spine. She described the pain as a dull ache after standing or sitting for long periods of time (over 3 hours). My thought was that it may be a postural issue, as we could see she had poor posture sitting in the chair during our evaluation. We went through repeated flexion/extension with her, with only the repeated extension causing pain in her lumbar spine. All AROM directions of the cervical spine caused an increase in pain in the suprascapular region. When observing the patient’s spine, it was clear to see that she had a flat lumbar curvature (no lordosis), along with some slight scoliosis. After the evaluation of the patient, the rest of the session was used to instruct the patient on proper sitting, standing, and lifting mechanics as well as. We also gave her a lumbar roll to use during sitting to improve her posture. After trying the lumbar roll in the chair, she immediately felt a decrease in symptoms in her lumbar spine as well as in her upper back. The plan is to have her work on her posture come back in within two weeks to see if the symptoms have improved. If she is still having pain, we may work on hamstring flexibility as that was minimally limited.
John Knowlton
In clinic we were treating a 65 y.o white female who was sent to PT for trigger finger of the left thumb. The pt was a librarian at the local university. Pt c/o pain and inability to move her thumb. My initial thoughts were this doesn’t look like trigger finger because her PIP was not in a flexed position, but maybe a neurological issue because she could not initiate movement at the PIP of her thumb. The patient had arthritis of her 1st MCP joint. Pt had pain at the dorsal aspect of her PIP of the 1st digit when passively moving into flexion. She had active motion at her 1st CMC and MCP. She had 4/5 MMT of her thenar muscle and no other abnormalities at the hand or elbow. We thought this was an issue with the innervation of the FPL, so we tried e- stim to try to facilitate movement but we couldn’t isolate the FPL. We found no other impairments of muscles innervated by the anterior interosseous nerve. We recommended the patient look into a NCV test. We worked on passive motion of the MCP, CMC, IP joints of the 1st digit to maintain available motion. We instructed the patient to continue to work on this at home. Our plan is to search the literature for similar patient cases or methods of treatment.
Dominique Norris
In clinic this week, my CI and I saw a middle-aged male with a complicated case. Long story short, the man had received a total knee replacement that was successful, but months later developed an infection in the knee that led him to be hospitalized and NWB for several months. Ultimately, the infection caused a weakened quadriceps tendon and resulting severe lateral patella shift, especially during knee extension.
My CI has been seeing him for a few weeks and has been able to increase the medial availability and decrease the lateral movement. When we got to the room to feel the patella available movement on both knees, I began to feel unsure about my palpation skills. The involved knee still had some swelling and a lot of extra skin which made it difficult to see where the patella was.
Fortunately, I felt comfortable enough to share with my CI my confusion and he helped me understand, see, and feel the patella tracking by both showing me with his hands and then letting me put my hands on as well.
Having one clinical experience already, and thus knowing the value of getting clarification when I’m confused definitely helped to motivate me to ask for help in this situation. In future weeks, I will remember this and find appropriate ways to get clarification, even if it may be embarrassing for me to admit.