Guddday all. Currently at Bentley out patients musculo and enjoying it so far. My last placement was at RPH WSC ortho inpatients. Lots of people with lots of very broken bones. Some really interesting cases clinically and also some interesting cases for other reasons. One of the things that got my attention was the way that different people handled their pain. One patient, when given the option of pain cover before ambulation, explained that it was not his "policy" to take pain killers. Three metres later he was revising his policy. On one hand a tough tattooed young bloke had still not mobilised five days post femur ORIF, and in the next room a 14 year old girl with a T2 to L4 scoliosis revision had sat over the edge of the bed without complaint 2 days post op. Whichever patient, they required treatment and in this setting it was made easier by the fact that, generally speaking, help was only a Tramadol away. Moving on to the outpatient setting as I have, I'm still treating patients who vary widely in the way they respond to their pain.
I had a new patient yesterday (an older man with an extensive history of lower back pain) who was referred by the SCGH pain management team for treatment of lower back pain and radicular symptoms in the R leg. In their referral letter they indicated the medications they planned to provide him with, including buprenorphine patches and a number of other high level pain killers. Additionally, he had been prescribed anti-depressents due to a session with the psychologist, during which he expressed ideations of suicide. Three previous rhizotomies had been performed with fleeting success. No previous PT. During subjective examination he said that he had not actually been provided with any medication, and was frustrated by this.
Subjectively it was difficult to pin down aggravating factors at first. "Movement" seemed to be the main aggravating factor, but continued movement was also the main easing factor. Further questioning identified movement or loading in flexion (sit -stand, doing the dishes) produced most of his symptoms - stabbing 8/10 pain. Despite this, he presented as someone who was trying not to be limited by his pain. He still walks around the park, just has to sit down for 10 minutes half way round. Very interested in mechanics and is always tinkering with cars. Does all the house work at home. During the examination, his resting pain was 0. He consented to objective examination.
The objective was shortlived. Looking at his referral, I expected that would be the case, but his subjective and the manner in which he spoke suggested we might be able to do more than I had first intended. During active movements his demeanour changed significantly. He did not want to move because he knew he would experience that pain. He turned from a confident patient to someone who was afraid to move. I did a brief neuro examination before we terminated the session. He has agreed to return to continue objective examination. I know I have to further modify my examintion and I'm reasonably happy with how to do that (although suggestions always welcome). My issue is the fact that during my subjective examination I didn't identify that fear. The referral letter was a warning, but the presentation of the patient gave no indication before objective. The change was almost immediate.
I'm just wondering if anyone else has had a similar experience. I guess we'll see how he goes next time, but if anyone has some word of wisdom I'm all ears.
1 comment:
Hey Martin,
Yeah it's odd that you say that about this patient and how his attitude changed as soon as you started the objective.
I found that a lot at my placement in SCGH ortho inpatients- especially the elderly population. At rest their pain was so well controlled they were very happy and enthusiastic with subjective questioning etc. But as soon as you started moving the limb/ body part and causing pain their mood totally changed! The physiotherapist and myself often sat people out of bed with them screaming at us(eg 90 yr olds- day 4 post THR with declining fx), though I'm not sure you'd like to follow this rule for outpatient musculo!
I think you did the right thing by cutting the objective short because if you had persisted through the objective it would be unlikely your patient would return. My advice for your query about identifying these patients in the subjective:
? try looking at their reported pain levels eg if they tell you when they bend over pain is 9/10. This might give you an idea that it may only take something little to inflict ++ pain & give you a very upset client.
? I think also its the patients who are the most depressed that change their moods so quickly. So noting that this patient was seeing a psychologist would be a red flag??
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