Clinic reflection

13/12 Oh dear - a male returning patient who does not wear underwear "because of his eczema, " but he was asked not to return without wearing something. He "doesn't mind" - but I do. I'm taking no chances and his trousers remain on. I know it's wrong, but I hope he doesn't come back. I gave the best treatment I could and also practiced a couple of the techniques from the interconnected tissue course that I haven't used in a while. Good for him, good for me!


10/12 Today I saw a nice old lady who wouldn't remove any of her clothes! I had to soft tissue the LES and glutei through a full skirt, over a slippery underskirt and tights. I doubt that this was in any way effective and the session seemed to drag on forever. I didn't say anything to her, but now I wish I had. I need to address these issues for the comfort of patients. Then they can make a decision after I have at least made my suggestion and explained the advantages.

Formative OSPE / Formative CCA

Why is it stressful when it isn't even the real thing? I didn't do too badly. One tutor remarked on my choice of a seated Tspine HVT and asked if it was my best technique. I replied that I was better at it supine and she advised me to use my best technique in an exam situation. Common sense really! I think I automatically used the technique I had recently been practicing the most. Unfortunately it was rubbish! Other than that though, things went well. It is always good to have a dummy run, even if it is a bit stressful. Deep down I think it is the fear of utter humiliation I don't like!

CCA - D High and I can't find my feedback sheet right now. Quite disappointed, but mainly at fault for a safety issue when I had to be prompted to write a doctors' letter about pins and needles (info prompted by screening questions) occurring in alternate feet twice in the last week (when the patient had her legs crossed when it was cold) and once in the hand, on the day of  the exam when she was carrying a heavy bag. This makes me realise how cautious we have to be in CCAs not to miss anything that could cause a safety fail! Just glad to have passed really, but confidence levels are pretty low...

Clinic reflection / Clinic reports

I was pleased to have another opportunity to use a new technique learned in the obstetric elective, although once again, the patient was not pregnant. This time a patient reported heartburn during the systemic questioning. Her primary presentation was intra scapular pain and as part of my treatment was seated anyway, it was easy to include a new seated technique to help with heartburn. I had not practiced it very often, but I think it went well and the patient was comfortable. It is not something you want to get wrong!

Clinic Reports:

Tuesday - C High
Friday - C High
Consistent at least!
Positive feedback with emphasis on strong interpersonal skills.
Need to work on following through from history and examination, directly into treatment and management plans, to ensure effective patient care.

Clinic Reports Autumn Term - Friday & Tuesday

Pharmacology tutorial at Darwin Court

Luckily for me, we have been instructed to prepare pharmacology tutorials at Darwin Court and between us, we should have the basics covered. My contribution is shown below:




ANTIDEPRESSANT DRUGS

TYPE	ACTION	COMMON DRUGS	SIDE EFFECTS
TRICYCLIC ANTIDEPRESSANTS (TCAs)	Increase neurotransmitter levels at receptors By blocking re-uptake of: Serotonin Norepinephrine (Noradrenaline) (Venlafaxine has the same action – see “other drugs” below)	Amitriptyline Amoxapine Clomipramine Dosulepin Doxepin Imipramine Lofepramine Nortriptyline Trimipramine	Anticholerginic effects: Blurred vision Dry mouth Difficulty urinating Some cause drowsiness – useful for sleep problems in depression (eg amitriptyline) Overdose can cause: Coma Fits Fatal disturbed heart rhythm Prescribed with caution for people with heart problems or epilepsy
SELECTIVE SEROTONIN RE-UPTAKE INHIBITORS (SSRIs) Not generally prescribed before 18 years of age	Block re-uptake of: Serotonin	Citalopram/ Escitalopram Fluoxetine Fluvoxamine Paroxetine Sertraline	Nausea Vomiting Possibly at beginning of treatment: Anxiety Headache Restlessness (Fewer side effects than TCAs)
MONOAMINE OXIDASE INHIBITORS (MAOIs) Issued with a card detailing prohibited drugs & foods Used less frequently than TCAs & SSRIs	Block breakdown of neurotransmitters, mainly: Serotonin Norepinephrine (Noradrenaline)	Moclobemide Phenelzine Isocarboxazid Tranylcypromine	Combined with certain drugs or foods rich in tyramine (eg cheese, meat, yeast extracts, red wine) may cause a dramatic rise in BP with headache or vomiting Overdose can cause: Muscle spasms Death Prescribed with caution for people with heart problems or epilepsy Positive side effects: Especially effective in people who are also anxious or suffer from phobias

Other drugs: Duloxetine, Flupentixol, Maprotiline, Mianserin, Mirtazepine, Riboxetine, Trazodone, Tryptophan, Venlafaxine.

Lithium is used to treat manic depression. In some cases it is used with an antidepressant for treating resistant depression.

ANTIDEPRESSANT DRUGS

Depression is thought to be caused by a reduction in the level of neurotransmitters (excitatory chemicals) released in the brain.

Neurotransmitters are constantly being reabsorbed into the brain cells, where they are broken down by the enzyme monoamine oxidase.

Antidepressants increase the level of these neurotransmitters.

Moderate to severe depression (with despair, lethargy, loss of appetite &/or sex drive) requires drug treatment, often over many months.

Treatment usually begins with a TCA or SSRI.

Antidepressant effects start after 10-14 days and may be 6-8 weeks before full effect is seen,  but side effects may happen at once.

Tolerance to side effects usually occurs.

When stopping, the dose should be gradually reduced over several weeks to avoid withdrawal symptoms.

DIAZEPAM / LORAZEPAM

An anti anxiety drug / anxiolytic / minor tranquilizer.

Also classed as a muscle relaxant & anticonvulsant.

A benzodiazepine.

Benzodiazepines:

Depress activity in the part of the brain that controls emotion

By promoting the action of the neurotransmitter GABA

Which binds to neurons & blocks the transmission of electrical impulses, thus reducing communication between cells

Preventing the excessive brain activity that causes anxiety

Side effects:

Daytime drowsiness

Dizziness / unsteadiness

Headache

Blurred vision

Forgetfulness/ confusion

Rash

Can be habit forming if taken regularly over a long period.

(Source: BMA New Guide to Medicine & Drugs, 7^th Ed, DK)

Source of information for pharmacology tutorial

Cranial Nerves Revision

Cranial Nerves - Detailed revision cards

Thoracic Spine / Ribs

Annotated diagrams; Technique and Clinical anatomy revision cards  - Thorax

Annotated diagrams; Technique and Clinical anatomy revision cards - Ribs

Annotated differentials textbook -  Chest pain

Visit to the chiropractor

I ran across the road outside BSO, slipped, flew through the air and landed on my coccyx at the feet of two policemen on the pavement. Yes it's true, bizarre and embarrassing! I woke up the next day (Saturday) and couldn't believe I wasn't aching, but saw it as a good reason to visit my chiropractor anyway and approach it critically as a practice visit. It is because of this woman that I chose this career (having found I couldn't study chiropractic in London)! Inspirational as always, no active movements, no soft tissue, lots of different thrusts (always successful) and a good chat. In and out in twenty minutes and feeling fine. Nice job! I want to be her.

Clinic reflection / Theory of technique revision

Today I was overwhelmed by panic, which with hindsight was unnecessary. A patient presented having been referred by us 6 months ago and sent away. She had since had all relevant medical investigations and had brought the results with her, including a recommendation for surgery - which she did not want. It was a complicated history and she was in a lot of pain, but I should not have felt out of my depth at all - but I did. She was quite unwell and was limping. When all the information was digested, it appeared that the most likely explanation for her various symptoms was that her large fibroids were compressing the femoral nerve. It was a frustrating case, as she did not want surgery, because she had suffered through previous surgeries, but it was likely to be the most successful course of action. I felt deeply sorry for her. When I had time to reflect, I realised that in future I should wait until all the information is gathered before I panic - meaning I over reacted to her appearance, initial presentation etc, before finding out that she had been fully screened and had brought the results of imaging. I think I was worried about having to perform several dcp exams under time pressure and being grilled about numerous differentials - and neither situation arose. However, I am glad I have included reviewing dcp procedures in my LPA!

Theory of technique - Q&A CCA prep (Keep it simple)!

SIJ

The many SIJ techniques include some articulations which I NEVER use and seem to forget about most of the time. Now I have them on my little yellow card and I intend to start using them until they become second nature. I'm not doing too well with fourth year technique sadly. My notes are all I've got to go on and they aren't great. Plus whenever I seem to practice something new with colleagues, we all seem to have a totally different idea about what happened in class! For this reason, I am never going to find out what really went on in the technique classes with TA on hip and knee, when I was off sick! I am actually quite disturbed by this.

Annotated diagrams; Technique and Clinical Anatomy revision cards - SIJ

Clinic reflection

12/11 A new patient this week was a dental student with mid back ache due to postural fatigue. She spent hours flexed over patients and had a long upper body. She provided the perfect opportunity to use a seated thoracic articulation technique shown in the obstetrics class. I performed it with the aim of encouraging extension and the patient responded well. I was only too aware of the effects of exam stress and felt that much of this presentation and the patients' brusque, frustrated manner was likely to be because of this. She confirmed this as she left!

I also saw a PhD student with low back ache and was challenged by her insistence on manipulation. I have heard many stories about this happening, but this was my first experience. The patient always had manipulation (in Greece) which "fixed" her and she wanted the same thing here and seemed frustrated by even having to complete the case history first! Fortunately, she was a perfect candidate for manipulation and felt better after a couple of lumbar rolls. I did wonder how she would have reacted if I had decided not to manipulate. Negatively, I expect.

Abdominal Examination

My least familiar examination - still makes me quite nervous if I have to perform one. Really not good enough at this stage, need to practice even more, despite getting some dcp routines signed off lately!

Abdominal Exam Revision Cards

Obstetric elective begins

4/11 My first elective begins. Obstetrics was my first choice and having already had a new mother as a patient this term and having been found lacking, I am looking forward to this subject. It turns out that the techniques we will learn can be used on anyone and the tutor has also promised to help us improve our techniques in general. This sounds too good to be true! This tutor has a great enthusiasm for his subject which is infectious, although he does manage to make pregnancy and birth sound like your worst nightmare and pregnant women sound like alien monstrosities!

Obstetric elective slides - including list of techniques - HURRAH!

Research paper recommended by S.S, written by S.S himself!

Lumbar Spine / Clinic reflection

I successfully performed a rib HVT on a patient this week for the first time, having achieved success on fellow students during my last few attempts. It was a good feeling. I much prefer to use a technique on a patient when I feel I have a good chance of success, whereas I know some of my colleagues perform techniques on a patient as soon as possible for the practice and because it is more likely to work on someone who needs it. I really need to think about this, as maybe it is my friends who have the right idea. At this rate, the course will end and there will be techniques I haven't even tried on patients! That is not where I want to be in June.

We are looking at lumbars in technique now and it is good to revisit this most familiar presentation. There is still so much to learn though it is frightening!

Annotated diagrams, Technique and Clinical anatomy revision cards - Lumbars

Annotated differentials textbook - Low Back Pain

General examination / Observations

General examination and observations - so easy to forget!

I think I usually approach tasks in a linear fashion and I am actually finding it quite useful to have set myself these tasks for the LPA and to be forced to fit them in around other obligations - namely the dissertation. Like any coursework or exam deadline, I find that I want to focus solely on the task in hand until it is completed and then I will move on. Having to divide my time now is painful but probably beneficial, although I do struggle to divide my attention. It also means that I am revising in bite size chunks rather than a tunnel vision cram of an entire subject. This is a new experience for me. I do feel that everything is really on the back burner until the dissertation is in though. It is difficult to think about anything else really.

Clinic reflection - Fibromyalgia

Today I saw my first fibromyalgia patient. Immediately I got the impression that this patient had no interest in getting better and had accepted this condition, almost wearing it as a badge of honour. She was booked in for a re exam, having been a long term patient for many years. It was clear that she hoped for this to continue. She was also enrolled in the chronic pain group. I found she responded nicely to some of the techniques I learned on the course at the weekend. However, it really bothered me that she talked incessantly for the whole appointment. I felt this prevented her from relaxing, but at the same time appreciated that it was likely she just wanted to talk! I was surprised at how strongly I felt about this but realised that this was probably as I was compelled to talk back, as I couldn't ignore her and I found this distracted me from purely focusing on technique.

Fibromyalgia - look it up and learn!

An Integrated approach to the interconnected tissues - external course

23rd & 24th October

This is my first real excitement this term. I absolutely loved this external course with one of our technique tutors. It re-ignited my interest in hands on work! I greatly admire the way this tutor works anyway and it was a joy to benefit from her experience and see some of the soft tissue techniques she uses. It gave me real pleasure and it was an inspiration to see her enthusiasm for her work. We spent two whole days learning many different techniques that felt really effective straight away. It gave me hope for the future and I felt more enthusiastic about trying to improve myself. It felt like something I really needed and my hands felt happy! I feel it has improved my confidence in my hands and shown me some effective, deep techniques that patients are likely to enjoy. I was so sorry when it ended! Yet, I feel strangely guilty and uneasy as there has been no dissertation work done this weekend.

Return to class / Respiratory Examination

I made my return to technique, having been persuaded by a colleague who volunteered to work with me, as we are all happy I am not contagious and I am back in clinic on Monday anyway, as I have no new outbreaks of rash. I am utterly shaken by being absent for three weeks! Although, this has given me some time to prepare CCA revision (see below), but not as much as I would like, as the dissertation is sadly, a fiercely competing interest.

I knew all along I didn't have shingles, but I understand why I was told to stay at home originally. The fact that a proper diagnosis wasn't reached does bother me, but I have realised that this is only because I cannot help thinking it had something to do with the patient who itched (even though this is unlikely) and this makes me feel uncomfortable. Reflecting on how terrible this has been, I have decided that I will be extremely cautious about anyone who describes itching in future and if I decide to treat it will be in gloves and I will give sensible reasons. I also see that I should have done this anyway as I was not happy with this symptom. Self care is more important than trying not to embarrass a patient in this situation or disagreeing with a tutor. A lesson learned the hard way.

Respiratory Examination revision cards

Bad news / CCA Preparation

My rash swabs are back and the results show harmful bacteria. However, it is clearing up now. I have been told to ring for an emergency appointment with the doctor if I get any new ones at all. Between this and reading papers for the dissertation I am not feeling at my best!

Pharmacology - CCA preparation for potential returning patient

Pathophysiology - the plan to nail it in time

I am considering how best to tackle this vast subject. I like the idea of the suggested approach above and I will be doing this with my colleagues in clinic, but I need to condense it further for myself. I would like to have three sentences to reel off about everything I should know. I am also trying to make up a clinic folder with snippets from another great book I found where the information is arranged logically and in short lists. This is an ongoing project! 

The Hip / Learning Contract

Annotated differentials texbook - hip

I am trying to organise my revision schedule around the technique syllabus, but I've already missed two classes, by being barred from the building!

Annotated diagrams; Technique & Clinical anatomy revision cards - Hip

Again, I am finding it really useful to make revision cards and test myself rather than trying to memorise lists and larger chunks of information. I am trying to re-learn old information in a more clinically relevant way. I have come to realise that I am a very visual learner and I need to organise information into subdivisions and patterns in a way that is suitable to look at often and quickly refer back to. It is also a good start for me to finally bring together all the varying sources of differentials and try to get them together on the same page by annotating the textbook. However, I still feel that I am trying to generate the information that I need to learn rather than actually learning it. I just hope I have it sorted out in time for exams!



Learning contract:

LEARNING GOALS	ACTIVITIES & METHODS	EVIDENCE (Reflective journal including all goals)	ASSESSMENT	EVALUATION / CRITICAL REFLECTION
Review technique – theory & performance, including mechanism, effects, evidence base (if possible), when to use & expected results. Prepare the same for electives. Integrate into clinic.	Self directed study – preparation of revision diagrams. Technique practice with peers. Widen variety of techniques used in clinic. Possible practice visit. Manus talks/courses. Reading (inc. harmonics).	Registers – Attendance of technique classes, all clinics & electives. Revision diagrams. Anonymised case histories. Written confirmation of any practice visits. Log Manus attendance. Notes re reading.	OSPE. CCA. Log of techniques signed by clinic / technique tutors. Peer feedback. Patient feedback. Clinic tutor report.	Improve confidence.
Focus on HVTs from 3rd year. Aim to cavitate areas in which unsuccessful so far eg O/A, Ribs, S/I, C/T supine & prone & improve others, including Csp left handed & seated Tsp. Review junctional areas. Improve specificity. Focus on palpation.	Attendance of technique classes. Technique practice with peers. Widen variety of techniques used in clinic.	Register of technique classes. Personal log of techniques performed with peers. Anonymised case histories.	OSPE. CCA. Log of techniques signed by clinic / technique tutors. Peer feedback. Patient feedback. Clinic tutor report.	Improve HVT success rate.
Focus on improving depth & specificity of soft tissue techniques.	Technique practice with peers. Widen variety of techniques used in clinic. Sports massage course. Possible anatomy trains course. Other courses.	Personal log of techniques performed with peers. Anonymised case histories. Written evidence of any courses attended.	OSPE. CCA. Log of techniques signed by clinic / technique tutors. Peer feedback. Patient feedback. Clinic tutor report.	Improve confidence.
Review examination skills, including special tests.	Self directed study – preparation of revision documents. Technique practice with peers. Widen variety of techniques used in clinic.	Copies of revision documents. Personal log of techniques performed with peers. Anonymised case histories.	OSPE. CCA. Peer feedback. Clinic tutor report.	Improve confidence, speed & understanding.
Revise anatomy & surface anatomy. In order of focus of technique classes & electives.	Self directed study – preparation of revision documents by region. Include refs to pathologies, special tests & techniques.	Copies of revision documents.	Possibly peer tested Q&A style. OSPE.	Improve knowledge & speed of recall.
Review clinical exams. Focus on performing quickly & justifying.	Self directed study. Practice with peers.	Study notes. Anonymised case histories. Possible log signed by tutors/peers.	CCA.	Improve knowledge, understanding & speed.
Review pathologies & pathophysiology.	Self directed study.	Study notes.	Possibly peer tested Q&A style.	Improve knowledge & speed of recall.
Improve hypothesis formation & differentials.	Study group, using anonymised case histories.	Log of attendance of group. Group notes.	CCA / tutor reports.	Improve knowledge & application in clinical setting.
Review pharmacology. Focus on musculoskeletal side effects.	Self directed study.	Study notes / table / diagram	Possibly peer tested Q&A style.	Improve knowledge & speed of recall.
Develop knowledge base of specific techniques addressing the lymphatics through research project.	Self directed study.	Dissertation. Prepare presentation, possibly for a tutorial.	CAE.	Learn about interesting new techniques & possibly share them.

Bex Morrison October 14, 2010

Horrors! / Cardiovascular Examination

This is now my second week of absence from school, so I have to mention it really. The weekend after seeing my itchy patient, I too began to itch, but unlike him, I developed red painful bumps. Horrors! I don't really want to dwell on this. Shingles has now been ruled out, as I keep getting more of them in varying locations. I have had swabs taken. I the meantime I am trying to do some work. I am getting my LPA plan in place and this should help me prepare for the mock CCA, however, I seem to be devoting more time to the dissertation. An unavoidable problem and I am desperate to get it out of the way, but I really want to revise too and I can't stop itching!

However, this means I have more time to make revision cards! Testing myself really is the only way I learn. Sadly I realised this a bit too late and have spent the past few years making really long lists that I can't remember. Strangely enough, I always made hundreds of little cards for FD - I think those LRP questions made it easy to do it. It is much harder with anatomy / NMS style information. 

Cardiovascular Examination revision cards

Same for the knee...

Annotated diagrams; Technique and Clinic anatomy revision cards - Knee

Annotated differentials textbook - knee

Annotated differentials textbook - popliteal fossa