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

Ankle and foot

Fortunately I have not experienced much foot pain, but just enough to know how annoying it can be. Even a few hours with a blister can drastically alter the way we walk and compensatory aching can occur elsewhere in no time. Unlike some of my classmates, I am foot friendly, although I admit I have been lucky so far in managing to avoid any unpleasant encounters! I also like my own feet and I am always happy to have them worked on. I really can't understand anyone who isn't.

I have seen only one or two primary foot problems in clinic, but I have found that it is often beneficial to treat the feet when patients present with hip or knee complaints. This is relieving for them and enables me to revise. I am finding it is true that if you don't use it, you lose it - quite quickly sometimes. It has pleased me that peer feedback has been that my pressure/grip/fixing is a lot firmer now and my treatment feels more effective.

I am a visual learner and I really need information written down in front of me. This means I generate a lot of notes and then spend hours trying to summarise them! My plan this year is to collate all the information I have gathered and arrange it by anatomical area. I am in the process of annotating the second and third year visual aids for technique, with any useful information from the first year handbook, media on demand videos and notes I have taken in class over four years. Then I intend to generate memory jogging technique revision cards - I really need to widen my repertoire and keep using all the techniques we have been shown, not just a few old favourites. I am also making clinically orientated revision cards for anatomy/surface anatomy and examination, including orthopaedic tests - see below for ankle and foot.

Ankle/Foot annotated diagrams; Technique and Clinical anatomy revision cards

I am also compiling information on differentials. I am annotating a differential diagnosis textbook (the origin of VINDICATE so it seems) with information from clinic, two other useful textbooks and old fourth year notes. It really bothers me that there is no definitive well sourced list and so much information given to us is actually not entirely correct! See below for leg, heel foot and toe.

Annotated differentials textbook - leg, heel, foot and toe

Clinic reflection

1/10 My new patient today was a new mother and I felt quite prepared for this, having seen a very acute new mother in my first summer clinic - when I missed lots of questions in the case history! However, when I presented to a tutor this time, I was quite harshly reprimanded for missing some questions I still hadn't thought of and also for not knowing about specific types of braces/supports that can be used during pregnancy. It struck me that there are many questions that need to be asked about the pregnancy itself, labour, delivery and aftercare and I need to know about this, as it is definitely an area of interest for me. I will be taking the obstetrics elective later in the term, but following this experience today, I have requested/begged to be put in the expectant mothers clinic next term. I feel concerned about other specialist areas I may not be exposed to and I am going to give this some consideration.

29/9 My new patient today had a rib lesion and I am disappointed that I asked the tutor to perform the HVT  without even trying it myself. I had not performed a successful rib HVT yet and I was reluctant to inflict my technique on an acute patient. However, I still felt deflated by the experience. Fortunately for me, I had a very understanding tutor who advised me that ribs were EASY and before I knew it, an unsuspecting colleague was laid out on the plinth before me. I was not allowed out of the room until I achieved a rib HVT. I did a lap round the plinth to celebrate.