week three blog: third placement

Situation: A patient was referred to the clinic for a mild MCL strain which resulted from an accident at work 3weeks ago. The patient presented on elbow crutches with an obvious antalgic behaviour.

Task: My task was to assess this patient and devise an appropriate management plan.

Action: After a few minutes of taking a subjective history it was clear that there alot more going on then just a mild MCL sprain. The patient expressed a high level of pain from the knee into the foot on the left side. There was no clear relationship between the different pains and it was severely irritable. The patient also had a history of depression and was on workers compensation so there were a few contributing factors. As a result there was very little I could assess objectively as every small movement was painful therefore the was too much risk of false positive results, we concluded that they were experiencing allodynia as a symptom due to the hypersensitivity to light touch. All investigations came back as a mild MCL sprain with no serious pathology evident. Therefore I surmised that there was a large central component to this patient's pain experience.

Result: As a result of these findings, the acute objective was to maintain range of movement and strength and to find pain relieving positions. I explained to the patient that because the injury was now 3 weeks old, the pain that they were experiencing was becoming maladaptive and that it is important to move the knee through bearable pain so they did not decondition. I also monitored their symptoms closely to note any physical exacerbation objectively compared to the subjective reporting from the patient.

Evaluation: I realise that when I first read the referral I assumed it was a fairly straight forward patient. Clearly now I know not to assume anything from a referral letter and that although physical finding may be relatively mild that doesn't translate directly to the patient's experience. This patient was in a lot of pain and yet it appeared it was a mild mcl strain with minimal bruising and swelling.

Strategies: In future I will not presume a patient's condition from a referral form or previous investigations. It is important to do make an educated decision on a patient's presentation after a thorough subjective and objective assessment. I've also realised the importance of education in a central pain presentation or one with yellow flags as it is vital to reassure and explain pain to the patient to prevent catastrophisation.