judging pts

Ive just had a womens health placement in a public hospital and in the last 4 weeks I saw a variety of patients from different socio- economic groups. A number of the patients I saw were also very young. After reading their notes I just assumed that because they were so young that they would not be interested in a physio student coming to give them 25 mins of post natal education. Many of them also had complex social histories so I thought physio would be the last thing on their minds.
I went into their rooms just expecting them to tell me that they couldn’t be bothered listening so to just leave the physio info sheets there. However almost all of my younger patients were the ones who were most keen to listen and asked the most questions. It didn’t occur to me beforehand that these are the patients that are probably keen to learn the most because they haven’t been taught anything like this before. It was nice to have patients that were actually interested in what you were saying and it showed me that you shouldn’t judge patients just on their notes because they can suprise you

Building Rapport

Whilst treating a patient this week I learnt the benefit of being polite but firm with patients. I was seeing a lady who was 3 days post C- section to give her some post natal education. She was complaining of mod pain however refused pain medication as she preferred more natural remedies. This pt also had a very interesting PMH and the nursing staff had warned me that she could be very difficult and wouldnt do anything she doesn’t want to.
So the first time I went to see her, I tried extra hard to be nice and build some rapport with her so that she would be compliant. Which meant that I let her brush her hair, put on some hand cream, helped her walk very slowly to the toilet etc. However this meant that I had already spent 15 minutes with her before id even started my education. She was extremely friendly with me and listened to my advice and asked questions. By the time Id finished, an education that should have taken a maximum of 25 minutes had taken just over 45 mins.
From this I learnt that whilst building rapport with the patient is essential, we still have to be in control of the treatment session because our time is very precious, especially next year when it would have been just me on the ward.

Pschology

On my paeds placement i became very interested in the psychological effect of parenting a child with a disability.
I came across a lot of parents on my placement and it was interesting to see how different people managed different scenarios. I researched a whole heap of journal articles regarding stress, depression and illness amongst parents of people with disabilities and gave a presentation to the staff.
We get given some advice to manage parents whilst we're treating their children, however I don't think it is highlighted enough. I've finished my placement and I'm still not sure how to manage a depressed parent, I don't think anyone is sure how to manage the situation. However I do know that we need the parents to continue with home exercise programs for their children and therefor we need them to trust us and be in the right frame of mind.
In my brief placement I learnt that active listening was effective especially for people who just need to vent and talk, However for people who are more at risk of depression its not the be all and end all. People manage stressors best when they have an internal locus of control and a sense of self mastery. Its not about always being "feel good" and "lovey dovey" you need to empower these people to take control of their life to break the depression cycle, be a motivator not just someone who tries to empathise with them.

Red Tape

On placement with a government department, not a hospital.
I have never seen so much red tape in an organisation before. These people will hold meetings and achieve nothing, they discuss their policies and procedures more than they practise and the whole environment is inefficient. It was hard to swallow how many resources this organisation squandered.
I finished my placement and I am glad i experienced it, I learnt the effects that red tape had through all levels of staff, It breeds inefficiency. I know better understand that a workplace needs to have the right balance between policy and procedures and freedom for individual thought and decision making.
Has anyone else found a placement to be a poorly run organisation?

Continuing Education

My self directed placement I took part in dissecting the brachial plexus on a wet specimen, it was a fantastic experiance. More to the blogg point of view, the biggest thing i learn't from dissection is how much anatomical knowledge we have. It doesn't take much to remember that Real Therapists Drink Cold Beers. (roots, turnks, divisions, cords, branches), and without blowing out own trumpet we have a very good level of knowledge when it comes to anatomy. However, with a little bit of revision you can realise that there is alot more detail available out there on anatomy and knowledge that is relevant to practising physiotherapists.
I know we all graduate soon, just wanted to make the point that there is heaps more for us to learn.

international health

Returning from China and reflecting upon my experience it made me realise that our health system is so advanced compared to a coutrny like China. We are in actual fact very lucky to be able to be part of a system that prioritises health over the economy andf everything else. You do not realise till you go overseas and work that Australia is such a lucky country to live in. We have access to the public health system which has mostly recent technology and knowledge. Quality of life is such a priority here compared to overseas where theressuch limited access to modern rehab techniques and actual therapists. It opened my eyes to the systems in place overseass as well as the status of physiotherapists overseas.

how do you tell someone they need to reduce weight?

I had a few patients that were fairly overweight presenting with low back pain. After multiple sessions of treatment their low back pain improved signficantly so the focus of the treatment was on self manaagement and their HEP. The other issue as mentioned before was the excess weight they were carrying. I knew from my initial treatment with my patient that I would have to address this issue. The only problem was that it is a very difficult topic to bring up, and most perople that are overweight are sensitive to the issue. Discussing with my supervisor there were many methods you could use to approach the issue. The very direct way or mor subtley or almost not at all. I approached the topic and fpund that it wasnt that hard to bring it up. The next session however my patient made excuses for this that and the other for not exercising and not eating right. This then continued in the next session and unfortunately there was not much i could do as my placement drew to an end. So how effective was my cozxing and education I wonder? At least I know now how to approach patients with this issue but in terms of how long the impression will last is another matter.

unrealistic pt expectations

I had a pt on my rural placement who was referred to me by the OT student who told me that he was a bit of an angry man. He had a thalamic stroke 2years ago and functionally he is independent with ADLs, he was referred to physio because he was getting pain in his buttock when cycling on his static bike. When I saw him he gave me a long story about when he had his stroke and the current symptoms he experienced. He told me at the time of the stroke he was out in his shed and when he started feeling the symptoms of the stroke, which he didn’t know was a stroke at the time, he went to his car and tried to get in and struggled due to the weakness but managed to get himself in. He felt that the pain in his buttock was from when he was trying to get in his car he thought he injured his leg, he thought ‘a sinew had been detached’ and he wanted an x-ray to show whether or not this was true. He was not too happy with the treatment he got when he was in hospital and said no one would do an x-ray for him. After doing the whole S/E I did the O/E and he had no musculoskeletal problems causing the pain, his pain was on his ischial tuberosity which was why he thought he had a sinew detached. I told him there was no treatment I could do for him to relieve his pain but I could give him a home exercise strengthening program as he had slight decrease in strength. His reply to this was that he didn’t want an exercise program as he was happy with his static bike cycling he was doing. His expectations in coming to physio were for a referral for an x-ray. I told him that I couldn’t refer him for an x-ray and if he wanted an x-ray he had to go to his doctor to get a referral.
This case showed me that pt expectations of what we can do for them are sometimes unrealistic and there are times that there is no treatment that we can offer the pt to help their condition. Sometimes all we can do is give them education and advice.
In the future I will take note of pt expectations and beliefs and treat the pt as I see appropriate trying to get to their expectations while still being aware that some expectations may be out of our scope as physiotherapists and possibly unrealistic and therefore pt education may be the only management I can offer the pt.

independence vs safety

I treated an 83 y.o. lady who was admitted for rehab after having a cerebellar stroke. She is mildly affected by the condition and is independent with her ambulation with no aid. Prior to admission, she lives alone in her own home and is independent with all ADLs. I decided to assess how well her balance is and so I did a Berg Balance Scale on her. Her score was 44/56 and therefore is a falls risk. Without me even suggesting to her any walking aids, she said to me that she doesn't want to be walking with any frame or stick and wants to be on her feet for as long as she can. I have no worries about her ambulation indoors (as she is walking around the ward by herself) but I am worried about her outdoors mobility (with the uneven surfaces and environmental factors). Prior to her discharge, i talked to her about her outdoor mobility and how it is very different to indoors. I also did the dynamic balance assessment (external displacement) on her to show her that she couldn't save herself appropriately if she is nudged by someone in the shopping mall or on the streets. I also told her that she will have a risk of being hospitalised if she does have a fall. I know that she doesn't like the idea of walking aids so I gave her a brochure which includes a range of 4WW which she could use as an outdoor walking aid to improve her safety. I am not sure if she went to get one in the end but I know that I have done all that I could in terms of educating her regarding her safety outdoors. I have also referred her to day therapy for more rehab.

Realising what my learning style is...

On the first day of one of my placements we did a learning style questionnaire. I was somehwere between a theorist and a reflector. One thing that the questionnaire mentioned was that theorists/reflectors require ++preparation prior to doing something. I really thought about this and agreed that this was soemthing that would benefit me. From writing notes to planning out a treatment session, when i have a plan i seem to perform alot better with greater confidence and efficiency.

I applied this to my practical sessions durin this placement by making sure i had thought about a plan before attempting notes or treatments sessions. It worked well and my supervisor noted that my confidence was improved.

Later in my prac (when motivation stated to reduce) i wasnt preparing for my treatment sessions. I was just doing things on the spot and funnily enough my supervisor picked up on this and told me that i was not as efficient or confident as i had been previously.

I have learnt fromthis situation that my learning style is most definitely theorist/reflector and that preparation is essential for me to perform well.

Comfort care

On my neuro placement, i treated a 92 y.o. male with parietal subdural hematoma as a result of a fall. Prior to the fall he is independent with all ADLs and ambulates with a walking stick. When i first see him, he appears confused and weak in his lower and upper extremities. He couldn't communicate well with everyone and has developed dysphagia. He also has anosognosia. I worked on his sitting balance all week and did not achieve much. It was also hard for nurses to transfer him with the pulpit frame due to his weak legs and trunk muscles. He is not taking in adequate food or fluid. The doctors and the family agreed to provide him with 'comfort care' instead of active treatment which will include tube feeding. I wasn't too sure what 'comfort care' means in terms of physiotherapy. My supervisor then asked the doctors if they are happy for physiotherapy to continue just to make transfers easier on the nurses. They were happy for that and so i continued treating that patient just to improve his sitting balance and ability to sit to stand to make transfers easier. However, one evening, when the patient was placed on a high back chair, the patient was seen kneeling on the floor trying to get back on to the bed. I felt responsible for the event as I was the one who encouraged the nurses to sit the patient out on the chair for as long as he could tolerate. It didn't occur to me that the patient also has lack of insight of what he is able to do and what he needs to do to get back into bed (i.e. call the nurses to assist). Since then I have decided that he could only sit on a recliner chair and that there is not much purpose in keep working on his sitting balance when sitting and transferring him via pulpit frame will be unsafe for him and the nurses. He is also seen on a few occassions trying to climb out of his bed trying to go to the toilet, and he has rails put up on the sides of his bed since. The nurses have been transferring him with the hoist after the incident and is now waiting for a HLC nursing home.
I realised that when treating a patient, we have to be realistic on what a patient is capable of and progressing a patient who is cognitively impaired is sometimes inappropriate.

Frustration

On a recent placement i was given a patient to treat who had a head injury. From the first session with him, he would thump his PCA, PT and me. It was frustrating because we couldnt punish him.

After talking to the clinical psych we implemented "gym rules" which said "keep hands and feet to ourselves, no hitting, punching etc...". This worked well. The patient did require constant reminders of the rules, but generally there was no thumping after it was implemented.

The treatment session i didnt start with a review of the gym rules, the patient started being physical. He continued to be this way even after being reminded of the rules. Then as i was sitting next to him, he scratched my eye with a bean bag. I reacted quicker than i could think and i took the bean bag from him and gave him an assertiveish/very annoyed/angry talking to. I mentioned that he was out of line, and that his actions were unacceptable. I was fuming!

For the rest of the session he did nothing...just sat there on the bed. We tried hard to get him to walk with our assistance but he declined. We ended up just t/fing him to his w/c and letting him go back to his room.

The following session i started off by mentioning to the patient that i didnt hate him and that i was looking forward to having a good session with him that day. We reviewed the gym rules together and actually had a good session with no thumping or innapropriate behaviour.

I learnt in this situation how difficult it can be to deal with children with head injuries. I learnt that there must be a consequence for their actions and being in a position to take something of value away from this child may have given me more leverage to control his behaviour. The problem was that there isnt much we can actually limit or stop him from doing.

patients with dementia

2nd week of my neuro placement. I had to treat a patient who came in with increasing confusion and slurred speech (with ? aphasia). There was nothing much written in his file regarding his social history and past medical history as the patient couldn't communicate well with the medical stuffs due to his confusion or aphasia. I went in to do a mobility review on the patient. The patient couldn't perform any movements on command but is able to do them voluntarily. He also had some difficulties understanding my instructions. i was thinking at that time that he has both apraxia and aphasia. My supervisor asked me if there is any other pre existing conditions that could contribute to his current confusion and i looked at his PMH and he has dementia. My supervisor told me to keep my instruction short and simple with this patient. I managed to get his cooperation and was able to assess his mobility. When we left the patient, i had a discussion with my supervisor regarding how much of the patients presentation is dementia and how much of it was due to aphasia and apraxia. I then called his current hostel and i found out that he is from a dementia specific ward and he is usually good with following commands. The other thing that could contribute to his current confusion too was the fact that he is in a different environment than what he is use to. Since then i decided to keep my instruction short with him and that i don't have to explain much about what i am doing.
This has taught me that when it comes to patient with dementia, they sometimes could also present with apraxia and the fact that he is confused doesn't mean that he has aphasia. I have also learn to keep my instructions very simple with patients with dementia.

wrong diagnosis

Third week of my neuro placement. A patient was admitted for a ? TIA due to increasing weakenss in the legs and 3 falls in a week due to her legs 'collapsing on her'. I did a full neuro assessment on the patient and she doesn't have any unilateral motor deficits or any neuro deficits. She has bilateral weakness in her LL (gr4). I assessed her functional tasks and she required maximal assistance to sit to stand (and could only stand for 5 secs before sitting down again). She gets very SOB on attempting to stand. She also desaturated to 82 just with attempts to stand. Her SpO2 in the morning was 88. I got the nurse and she put the patient on O2. I decided to stop my assessment there. I talked to the patients husband and according to him, the patient has been very inactive for weeks and she requires assistance going in and out of bed at night and could only manage walking short distances within home (i.e. bedroom to the lounge). I told my supervisor my findings and I told her that it couldn't be TIA because the patient has had the legs weakness for weeks and TIA usually resolves within 24 hours and the fact that she desaturates with attempts to stand, that suggests some other pathology that could be happening at the same time. Next day, I tried to see the patient again but the nurses told me that she had a MET call. She was transferred to another hospital that evening due to a large PR bleed. The patient also has a very long list of PMH which includes Cancer and therefore her current presentation might have been an exacerbation of her previous conditions. The fact that she is being diagnosed with a ?TIA doesn't really justify the signs and symptoms that she presents with. From this experience, I have learnt to just not to accept any uncomfirmed diagnosis and to go with the signs and symptoms that the patient presents with.

Hypoxic Drive to Breathe

Prior to seeing my patient who was admitted with Type 2 Respiratory Failure, I checked the medical chart for his cardiovascular status. I noticed that his SpO2 was at 97% with 2L entrained Oxygen via a BiPAP machine. This raised concern, as the patient would have relied on hypoxic drive to breathe considering his diagnosis. This meant that a small rise in his oxygen levels could have caused a huge reduction in his ventilatory drive, which could have resulted in further deterioration of his resp status. In addition, I recalled that the doctor had specifically noted that his SpO2 should be targeted at 88-92% on BiPAP.

The ward nurse didn’t seem to know anything about the situation, and I was not sure if I was allowed to adjust the setting on the BiPAP machine. So I approached the NIV physiotherapist, whom happened to be in the ward that morning, to seek guidance. Immediately, she notified the nurse and requested that the flow be adjusted to ensure his SpO2 was within the targeted level.

I was reminded that, as a clinician, it is essential that I am thorough with my examination of a patient and be analytical in every situation because this could ultimately prevent any unnecessary mishap. Also, it is important to approach the most suitable clinician in seeking the most appropriate step to take.

Total Knee Replacements

On my rural placement I saw two pts post TKR, the first was an elderly lady in her 70’s and I saw her for her r/v 2/52’s post-op, she was doing well with her rehab, getting over 90° active flexion and only had a few degrees of quads lag but this had improved greatly from her pre-op status. She was compliant with all her exercises and keen to do more. The second TKR was a man in his 50’s, he requested to be sent up to the hospital I was at, as it was closer to his home, after a week post-op in the hospital where he had his operation, in a nearby bigger country town. When we went to see him he only had 40° passive flexion and no activation of his quads, he was in a lot of pain when he tried to move his operated leg and he had quite a bit of swelling around the knee and his quadriceps was extremely tight. He told us the physio management and treatment he got in the hospital where he had his operation was not good at all, he said he hardly saw the physios and the CPM machine was left in his room for him to put on and use himself if he wanted. We couldn’t be sure that he was giving an entirely accurate description of his treatment but from the state of his leg it didn’t look as if he had had very much intervention. We had to do some intensive treatment on this man to try get some movement happening in the knee and get the quads muscle firing. We put him on the CPM machine for a few hours during the day and got him doing passive and active quads exercises. Before the quads exercises we tried to release some of the tension in the quads muscle but he could only handle gentle massage as anything deep caused him intense pain. After a bit of massage his quads started firing a bit. By the end of the week and my placement he was doing a lot better but still not good enough to go home.
From these two cases it really showed the importance of good management post-op. If you took a 70 year old woman and a 50 year old man you would expect the younger of the two to recover better, and even though the woman was a week further in her rehab when I saw her, the man was not even close to the same level after a few days of seeing him which would have been at his 2 weeks post-op mark. A number of factors go into the recovery of a pt post-op but in these cases I think one of the major reasons for the poor recovery of the second case was due to poor post-op management. It also shows that the first few days post-op are extremely important and good management and treatment from the start can cut down the number of days it takes to recover but conversely poor management and treatment from the start can extend the recovery period greatly.

Depends on the supervisor

I have had the unfortunate experience to have to repeat a prac due to being incompetent. I was absolutely devastated to have had to repeat 4 weeks which i could have had off. Having to repeat the placement has made me realise how much it depends on how well you get along with your supervisor. on my initial placement the supervisor was such an intelligent person that the expectation for us to be have that same amount of knowledge. The teaching style was very focused on independent learning and it was expected that your clinical reasoning skills were fine tuned. The on repeating the prac I have found it SO much easier. My supervisor is very open and friendly and completely down to earth. They give you positive feedback constantly rather than the constant negative comments that i was previously receiving. On my initial placement after not having a mid way placement i was told 2 days before finishing that i was to fail. Just the unfairness of it all really made me fume. To think that had i been on another hospital i would have passed instead of having to do back to back placements from Feb to now. Despite the setback I have learnt alot more from the current placement I am at. Its been really helpful learning environment even though my confidence completely dropped after the initial attempt.

6MWT

A patient with Idiopathic Pulmonary Hypertension was admitted to the hospital respiratory ward for further investigation due to ‘failure’ of achieving the targeted distance in her most recent 6MWT, as was told by the clinical physiotherapist. She expressed her disappointment during my subjective assessment, as it was explained to her that she has to ‘pass’ the 6MWT before she could be prescribed a specific medication that could prolong her lifespan. In other words, if she fails the 6MWT again she would not be given the medication. She had also stated that her right patella was removed and the knee joint was fused secondary to OA. This meant that she was not able to flex her knee during ambulation and would thus slow her walking speed. To complicate the matter, she had acquired LRTI in the hospital.

As she had not been out of bed on my initial session with her and her Obs and BP were stable, I decided that ambulation was the most appropriate intervention. I observed that she became quite SOB after about 10m of ambulation, so I asked if she wanted to sit down. (Her SpO2 was within normal limits) She declined and said “it’s alright, I can do this.” As we resumed, I realised that her SOB had increased progressively but the patient did not want to stop until she walked back to her bed (20m). Nonetheless, she recovered in about 2-3 minutes with relaxed breathing and other coping strategies to reduce her SOB.

On hindsight, I realised that the likely reason for the patient being so determined to keep walking despite mod-severe breathlessness was her perception that if she kept walking she would eventually be able to ‘pass’ her 6MWT (which was to be performed in a week). As a clinician, I should have insisted the patient to stop and rest to avoid any unforeseen circumstances. The following day, I ensured the patient understood that the 6MWT was not about passing or failing. It was to determine her functional and cardiopulmonary status and whether she was able to adequately manage her SOB. I also assured her that her speed limitation secondary to the fused knee would be taken into consideration.

Strange case

I had a pt who presented with swelling around her ankle, mainly around the lateral malleolus but also slight swelling across the anterior aspect of the ankle as well as the medial side. She had a constant 5/10 pain along the anterior aspect of her lower limb about ¾ of the way up (below the knee) and down to the ankle. Nothing she tried eased her pain but her pain increased over the course of the day especially with prolonged standing or walking. She had no history of injury, the pain just started one day and she noticed the swelling. She said she had been to the gym three days before it started but she just did her normal routine and didn’t roll her ankle or anything. She went to a doctor who thought she had just sprained her ankle so he gave her a cortisone injection (a bit weird I thought); this didn’t affect her pain or swelling at all. So she went to another doctor for a second opinion and they referred her to us. She had had an x-ray which showed nothing abnormal and the second doctor had also referred her for a bone scan (which was booked in to be done 5 days after I saw her). I assessed her and had no findings that I could make a diagnosis on. Her ankle stability tests did not show anything significant. She had pain with dorsiflexion and plantarflexion both active and passive and her inversion and eversion were pain free. She was TOP over the medial aspect of her tibial shaft but not TOP around her ankle joint. None of the subjective questions revealed red flags but because she had no findings that correlated well I decided not to try treat the swelling with ultrasound or any other modalities for fear of a more sinister pathology. All I could give her was some advice to try a compression bandage to reduce the swelling and I gave her some gentle AROM exercises. I advised her to contact us once she had got the results from the bone scan and then possibly with a diagnosis we may have been able to know how to treat her more effectively, if treatment was indicated. Unfortunately by the time I had finished my placement the pt had not got back to us which could have been because physio treatment was not indicated but unfortunately I’ll never know, it was a different presentation to what I’ve seen before so I was curious to know whether or not the scan showed anything and a diagnosis was made.
This presentation highlighted the importance to me to really be aware of red flags if the objective examination doesn’t seem to add up, even if no subjective red flags are highlighted. I don’t know if it was a red flag situation but I didn’t want to take my chances and when discussing it with my supervisor she agreed with what I had done and also found my findings didn’t point to a specific musculoskeletal diagnosis and it was a good idea to wait for further investigations. I can’t remember exactly but I think it may have been the fact that a bone scan was ordered that caused me to be a bit more aware of the possibility of a red flag situation. I would definitely take the same approach if similar situations occurred in the future and I hope I can stay alerted to the possibilities of red flags in my future practicing as a physiotherapist.

Learning and talking

On my paeds placement in China I was allocated to a room catering for a few conditions such as autism, Down Syndrome, ADHD and cleft palates. On entry I was greeted by blaring music, screaming kids and general mayhem. This was completely out of the ideal working conditions for a therapy room. In the general chaos of the room there was some sort of organised schedule and we managed to see the structure of the class.

From a physiotherapist point of view there was not much to apply in terms of therapy, despite this I actively questioned my fellow OT partner on methods of calming sensory seeking behaviours and encouraging play with autistic kids. I realised that how I was learning which was learning the theory and practical at the same time was so effective. I was able to think of strategies on the spot and apply the theory immediately. I then started to combine PT techniques that worked on balance and gross motor coordination which made more sense as you kill two birds with one stone. In this room the language barrier is most evident, joint with attention deficits made it extremely hard for the child to follow instructions. Being a room full of other kids and blaring music it will naturally be hard for any child to follow instructions. Observing the set up of this room reflects the infancy of the centres practice. What they have already is amazing but again there is much to work on. The staff aren’t even qualified in therapy yet are dedicated to their job. If only I had the language to explain to them techniques to assist the children I would feel more useful. I cant ask them if they know the rationale for the task the children do or if they know of any other techniques or even if they know the condition of the children they’re working with. It shows to me that language is such a powerful tool that can’t be taken out of the equation of communication.

:(

On a paediatrics placement, i went with my supervisor to see a 2mth old girl who had been in hospital from birth due tummy problems. The infants social situation was horrilble to say the least. For various reasons the mother and family were rarely present which meant that this infant would spend a huge amount of the day on her back in the cot only being held when she needed changing or medical attention (try and picture this...its not nice!)

The plan was to see this infant regularly for developmental play. When I was playing with this baby i was fine, i really enjoyed it. It was only once i got home that i realised how much this infants situation had affected me. I was overwhelmingly sad that night and i decided to talk to my supervisor the next day.

I expressed the reasons for my sadness to my supervisor. My supervisor encouraged me and gave me some simple advice. Suprisingly i felt a lot better following our chat. I was able to treat/play with this baby without my sadness getting in the way.

I have definitely learnt the value of debriefing with colleagues when something challenging happens at work.

Palliative Lung Cancer

I was to see a patient who was diagnosed with a 4th stage lung cancer (under palliative care) for chest physio review. Just to outline a little bit of the patient’s background: he was notified by his radiologist a few years back that he was suspected of having bronchogenic carcinoma. He was told that he would be referred to a hospital for further investigation. However, he waited for an appointment with the hospital that never came. He was recently admitted to the hospital by a ?neighbour when they saw his current condition.

The patient was on oxygen therapy via Venturi mask, and looked frail and exhausted. He was initially compliant with my subjective questioning, but became slightly agitated when I asked for permission to perform auscultation. He refused any form of physiotherapy intervention, and blamed the hospital system for not following up with him during his initial stage. I attempted twice to persuade him for physio, but was unsuccessful.

In such situations, I felt that any form of persuasion or intervention rationale became inappropriate as the patient had already decided that he would benefit from nothing at his current state. After consulting other physiotherapists in the hospital, I learned that although PT Rx could aid in the management of his respiratory condition, it was best not to push the patient since he refused even after several attempts. After all, PT intervention cannot be indicated without the patient’s consent. However, the approach should differ if the patient's recovery was more promising. In this instance, I could perhaps consider consulting the doctor or referring him to a clinical psychologist?