end week 1 cardio

S-We work on the Gen Med ward in the mornings, seeing patients with a variety of conditions. On Thursday we were to see a lady, Mrs A, admitted for increased SOBOE. From reading her notes we were able to ascertain that she had a history of COPD (despite never smoking) and a severe thoracic scoliosis. The doctors impressions on admission were ? exacerbation of COPD, ? worsening thoracic scoliosis. We then had a look at her x-ray and saw that her scoliosis certainly was severe, and was causing a marked reduction in her lung volumes, and could well be the reason for her dyspnoea. Looking at her blood results, she had no signs of infection, making an exacerbation of COPD less likely in my mind.

On further reading, we discovered that english was her second language and communication was difficult. She also lives alone on home oxygen (plus she is a CO2 retainer, meaning we had to be careful with oxygen levels), is short of hearing (wears bilateral hearing aids) and has 2 very supportive children.

T- Mrs A was flagged for chest physio, and our task was to conduct an initial respiratory assessment and come up with an appropriate treatment plan.

A-We entered Mrs A's room not really knowing what to expect. It soon became clear she had much difficulty understanding more complex sentences and questions. Luckily her daughter was in the room and I looked to her to help answer my questions. We went through a very thorough subjective and objective assessment, utilising Mrs A's daughter to answer questions.

We gathered very good information, and on putting the 2 assessments together we soon realised that her chest was not the main issue at play. Mrs A's scoliosis was severely restricting her ability to take deep breaths and was almost completely closing down on the right lung. This is a structural problem and something that Chris and I realised we can have little effect on. Rather than leaving it there however, we decide to follow up on the other concerns voiced by Mrs A and her daughter.

1.Mrs A mentioned she has just started choking when she drinks water, thus we decided to refer her to the speech pathologist with the thought she may need to be on thickened fluids?

2.Secondly, Mrs A's daughter mentioned that she and her brother were taking it in turn to stay the night at Mrs A's house. They felt she couldn't be alone because she couldn't hear the alarm on her oxygen tank when it signalled it was empty. This had been going on for 5 months at the expense of their own families! They were also currently doing all house-work, cooking, gardening etc and were finding it too much to integrate with their own lives. Their mother did not want to go to a nursing home, and they loved and respected her wishes, but they also identified that they needed some form of help. Chris and I referred Mrs A and her family to the wards social worker, to have a family meeting and discuss the services and options available to them.

3.Lastly, Mrs A previously walked with no aid, no more than 10 steps before she need to rest. Chris and I decided to test her out on a 4WW. This had so many benefits! She could fix her UL making her shoulder girdle available to be an accessory for breathing, she could sit on the walker if she needed to rest, and she could attach her O2 bottle to the frame for any outside trips! With the 4WW she was able to walk 3 times as far as her pre-morbid distance!

R-As a result of our extensive and thorough subjective questioning, Mrs A was referred to the correct departments and proper discharge planning could begin. I think we highlighted the crux of her problems and were able to get appropriately managed. I feel her diagnosis became more acopia, and we were the ones who were able to pick this up!

E-I was so happy with the result of our assessment. I think that as a first or second year student, I would have left the assessment thinking there was little I could do from a respiratory point of view-and felt that thus my job was done. Now, (as an almost graduate!!) I realise that there are so many aspects that go in to someone's discharge, not just physio. Our questioning flowed really well and as a result we could highlight the gaps in her care and refer her down the appropriate path. We were the first people to identify these gaps and I really feel it was because we built a rapport with her daughter and asked the right questions in the right order. For me, this case really highlighted the importance of the MDT and I feel that now it is something that will be in mind for every patient I see. Just because I can't do too many things to help there and then doesn't mean I don't know of people who can!

The weakness I identified, was that once I knew who she needed to see, I didn't really know how to go about it. I think that this is something that will come with experience and learning the certain procedures and protocol on my ward. I shouldn't be afraid to ask, because once we found out how to contact the speechy ad SW, they were more than happy to see Mrs A that day!

S-The strategies we used were
COMMUNICATION
-Involvement of Mrs A's daughter who could help translate
-Clear and slow voice when speaking to Mrs A, for ease of understanding and in recognition of her hearing loss
-If instruction were given to Mrs A, we asked for confirmation of understanding from her and her daughter
-Much use of body language and demonstration, particularly with using the 4WW (brakes, sitting to rest etc)
INVOLVEMENT OF THE MDT TEAM!!
-recognition of issues that can't be addressed by physio and appropriate referral to combat these.