Clinical would examine. A symptom is a subjective

Clinical
reasoning is a cognitive process in which a therapist uses clinical data,
patient choices, professional judgement and knowledge to evaluate, diagnose and
manage a patient’s problem (Jones, Rivett, and Twomey, 2004). This essay will
examine the importance of using clinical reasoning throughout the examination,
assessment, treatment, and reassessment processes of the given patient, Jakub
in the scenario. Clinical reasoning boxes will be used to illustrate how a
physiotherapist would approach this patient’s condition.

Finding
the source of the symptoms experienced by the patient is one of the first
things a physiotherapist would examine. A symptom is a subjective indication of
a disorder or disease, such as pain or weakness (The
American Heritage Science Dictionary). Having had a closed mid-shaft tibial
fracture 14 weeks ago, the patient would be expected to be in the consolidation
phase of healing where all the callus has become mineralised into woven bone
while osteoblasts lay down new bone tissue. This suggests that the pain,
stiffness, and weakness experienced could be a result of being in a full leg
cast for six weeks, followed by a below knee cast for a further six weeks. The
patient being in a cast for a prolonged time can cause problems such as post
immobilisation joint stiffness, muscle weakness, slow circulation, as well as
altered proprioception which would need retraining.

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Immobilisation of a joint can have serious effects on the
joint capsule, synovial membrane, ligament, and articular cartilage. Research
shows that after nine weeks, fibrils within the joint capsule and synovial
membrane can have a reduced mobility to glide (Akeson et al. 1987).
Consequently, prolonged joint immobilisation in a fixed position can cause
dysfunction of joints and this has negative impacts on muscular and neural
functions. Further research has also proved that joint immobilisation for only
three weeks can cause a reduction in the maximal voluntary contraction of the
muscle surrounding the joint, and a decrease in the maximal firing rate of
motor neurones supplying the muscle (Seki et al. 2001;
Kazuhiko & Hiroshi 2007). Therefore, this explains why Jakub may have
experienced stiffness and weakness following his injury as joint immobilisation
can cause muscle weakness and altered neural activity.

After
finding out the source of the symptoms, the second clinical reasoning box a
physiotherapist thinks about is the pain mechanisms involved. The International
Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory
and emotional experience associated with actual or potential tissue damage, or
described in terms of such damage”. The patient in the given scenario has very
clear aggravating and easing factors which helps to identify the type of
nociceptive pain they are feeling as mechanical. Further clues such as swelling
on his ankle implicate inflammatory pain.

This
pain is picked up by nociceptors (C and A? fibres), which are high threshold
specific receptors for intense stimuli and tissue damage. C fibres are slower
than the A? fibres because they’re unmyelinated and cause a dull sensation
whereas A? fibres are myelinated and cause a localised sharp sensation.
Therefore, as C and A? fibres respond to nociception and transmit nociceptive
information they are known as nociceptive nerves. (Julius
& Basbaum 2001; Wolf & Ma 2007). Both these sensory nerves carry
messages from the body tissues to their specific synapses on the dorsal horn
located in the spinal cord. Neurotransmitters get released from the presynaptic
membrane and diffuse across to their specific receptors on the postsynaptic
membrane of the next nerve. When a sufficient threshold is reached, an action
potential is generated and this nociceptive message travels to the brain where
it’s processed along with other contributing factors such as; the patient’s
emotional state and past experiences. As a result, the combined effect of these
factors makes the patient feel the sensation of pain.

In any case, the physiotherapist decides which symptoms are
to be provoked during the treatment and management.

The
patient’s subjective history is one of the most important things a physiotherapist
must obtain to safely develop a clinically reasoned plan for the physical
examination and management. This consists of developing a rapport with the
patient by using effective communication skills. The first part to a subjective
examination is a detailed and narrative format of the patient’s social history
followed by the history of present condition (HPC). A body chart is usually
completed next and this is where the physiotherapist asks the patient to point
to the location of the symptoms they’re experiencing. In relation to the given
scenario, Jakub is experiencing pain in his right ankle and knee therefore, it
is appropriate to quantify the pain using a scale such as a Visual Analogue
Scale (VAS). In addition to that, aggravating and easing factors determine the
severity and irritability of the symptoms experienced. Lastly, general health
and past medical history (PMH) are part of the subjective because it’s vital to
know if there are any underlying pathologies that could be precautions or
contraindications. The patient having Type 1 diabetes is an example of a
precaution that needs to be considered as it’s a condition that can affect bone healing. Clinical studies indicate that diabetes
delays fracture healing (Jiao, Xiao and Graves, 2015). Type 1
diabetes mellitus and Type 2 diabetes mellitus both increase fracture risk and
have several common features that affect bone including hyperglycaemia and
inflammation (Retzepi and Donos, 2010).

By
the end of the subjective assessment, the physiotherapist gains an
understanding on the severity, irritability, and nature of the symptoms to help
formulate a diagnosis for the patient’s problem. The severity of Jakub’s pain
is moderate as he described the ankle pain being 5/10 on the VAS. Equally
important is the irritability and this relates to how quickly he experiences
the symptoms from an aggravating activity and how they quickly disappear when
an easing factor is implemented. A patient with a high irritability would find
that their symptoms come on with minimal activity and take a long time to
disappear. However, if the time taken to aggravate is greater than the time
taken to ease then the patient will have low irritability like Jakub. This
suggests that the physiotherapist can examine his condition to the point of
pain. Other factors such his PMH can determine the nature of the symptoms
experienced which in turn influences the vigour during the physical
examination.

In
doing so, the physiotherapist gets an understanding of the patient’s perception
of their condition as it highlights the factors that may be contributing to the
source of the symptoms and pain. Additionally, it helps the physiotherapist to
clinically reason what physical assessments will be a priority and limiting the
extent and vigour of their assessment to suit the severity, irritability, and
nature of the initial diagnosis.

The
patient’s main problem is his ankle therefore the primary hypothesis could be a
problem with the gastrocnemius and soleus muscles along with compressed nerves.
To prove the primary hypothesis and consider safety issues, a list of
assessments the physiotherapist must carry out is needed. This is firstly done
through an observation where the patient’s gait as well as posture can be
analysed while using cutches and if incorrect, the physiotherapist can teach
them how to mobilise correctly and safely. Other observations include looking
at the swelling and colour of the patient’s ankle.

Furthermore,
the ROM of the ankle must be analysed followed by the length and strength of
the gastrocnemius and soleus muscles. A light touch/pinprick neurological test
on the common peroneal and tibial nerve must also be carried out. Palpation of
the ankle, gastrocnemius and soleus, the shaft of the tibia and the knee must
be carried out during the examination. Additionally, the active ROM of the knee
joint should be assessed and as the patient feels pain when sitting cross
legged, the muscle strength and length of the sartorius muscle should also be
tested. Lastly, the physiotherapist could assess the accessory movements at
both the ankle and knee joints as well as the muscle length and strength in the
quadriceps.

Regarding
treatment, the physiotherapist will aim for total patient management and this
involves addressing the primary problem of the patient’s condition which is
their right ankle. This suggests that treatment and management should be
applied specifically to influence signs and symptoms that are present such as
pain, joint stiffness, swelling and functional disability. Rehabilitation might
include therapeutic exercises to help restore range of movement, muscle
strength and stabilise joints which is beneficial for the patient because
they’ll be able to go back to doing functional activities such as taking the
stairs and walking to school rather than taking the bus. Education and advice
is another mode of treatment and it involves teaching Jakub how to continue his
rehabilitation at home and coping strategies to manage the ankle pain. As he
also experiences mechanical pain, manual therapy and exercise would be helpful.
For the inflammatory pain the use of RICE, tape, advice, or electrotherapy are
ideal. The pain relieving modality must be applied accurately to an appropriate
joint to produce relief of pain, considering the severity, irritability, and
nature of the condition (Petty 2011).

Prognosis
is the expected outcome of the physiotherapy treatment. The patient in the
scenario would get a good prognosis as the state of his condition is improving
and he’s in his teenage years. More importantly, Jakub is very active in his
school life as he’s part of the school football and basketball teams so he’s
more likely to adhere to exercise prescriptions.

In
summary, this essay has outlined the emphasis of using clinical reasoning
throughout the subjective examination, physical assessment, and
treatment/management process. Additionally, awareness of clinical reasoning
evidently helps the physiotherapist to identify which factors related to the
condition itself and the patient need to be considered. This avoids assumptions
and misdirection about the patient’s condition hence leading to effective
management and lastly, the physiotherapist can also reflect and learn from the
experience.Clinical
reasoning is a cognitive process in which a therapist uses clinical data,
patient choices, professional judgement and knowledge to evaluate, diagnose and
manage a patient’s problem (Jones, Rivett, and Twomey, 2004). This essay will
examine the importance of using clinical reasoning throughout the examination,
assessment, treatment, and reassessment processes of the given patient, Jakub
in the scenario. Clinical reasoning boxes will be used to illustrate how a
physiotherapist would approach this patient’s condition.

Finding
the source of the symptoms experienced by the patient is one of the first
things a physiotherapist would examine. A symptom is a subjective indication of
a disorder or disease, such as pain or weakness (The
American Heritage Science Dictionary). Having had a closed mid-shaft tibial
fracture 14 weeks ago, the patient would be expected to be in the consolidation
phase of healing where all the callus has become mineralised into woven bone
while osteoblasts lay down new bone tissue. This suggests that the pain,
stiffness, and weakness experienced could be a result of being in a full leg
cast for six weeks, followed by a below knee cast for a further six weeks. The
patient being in a cast for a prolonged time can cause problems such as post
immobilisation joint stiffness, muscle weakness, slow circulation, as well as
altered proprioception which would need retraining.

Immobilisation of a joint can have serious effects on the
joint capsule, synovial membrane, ligament, and articular cartilage. Research
shows that after nine weeks, fibrils within the joint capsule and synovial
membrane can have a reduced mobility to glide (Akeson et al. 1987).
Consequently, prolonged joint immobilisation in a fixed position can cause
dysfunction of joints and this has negative impacts on muscular and neural
functions. Further research has also proved that joint immobilisation for only
three weeks can cause a reduction in the maximal voluntary contraction of the
muscle surrounding the joint, and a decrease in the maximal firing rate of
motor neurones supplying the muscle (Seki et al. 2001;
Kazuhiko & Hiroshi 2007). Therefore, this explains why Jakub may have
experienced stiffness and weakness following his injury as joint immobilisation
can cause muscle weakness and altered neural activity.

After
finding out the source of the symptoms, the second clinical reasoning box a
physiotherapist thinks about is the pain mechanisms involved. The International
Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory
and emotional experience associated with actual or potential tissue damage, or
described in terms of such damage”. The patient in the given scenario has very
clear aggravating and easing factors which helps to identify the type of
nociceptive pain they are feeling as mechanical. Further clues such as swelling
on his ankle implicate inflammatory pain.

This
pain is picked up by nociceptors (C and A? fibres), which are high threshold
specific receptors for intense stimuli and tissue damage. C fibres are slower
than the A? fibres because they’re unmyelinated and cause a dull sensation
whereas A? fibres are myelinated and cause a localised sharp sensation.
Therefore, as C and A? fibres respond to nociception and transmit nociceptive
information they are known as nociceptive nerves. (Julius
& Basbaum 2001; Wolf & Ma 2007). Both these sensory nerves carry
messages from the body tissues to their specific synapses on the dorsal horn
located in the spinal cord. Neurotransmitters get released from the presynaptic
membrane and diffuse across to their specific receptors on the postsynaptic
membrane of the next nerve. When a sufficient threshold is reached, an action
potential is generated and this nociceptive message travels to the brain where
it’s processed along with other contributing factors such as; the patient’s
emotional state and past experiences. As a result, the combined effect of these
factors makes the patient feel the sensation of pain.

In any case, the physiotherapist decides which symptoms are
to be provoked during the treatment and management.

The
patient’s subjective history is one of the most important things a physiotherapist
must obtain to safely develop a clinically reasoned plan for the physical
examination and management. This consists of developing a rapport with the
patient by using effective communication skills. The first part to a subjective
examination is a detailed and narrative format of the patient’s social history
followed by the history of present condition (HPC). A body chart is usually
completed next and this is where the physiotherapist asks the patient to point
to the location of the symptoms they’re experiencing. In relation to the given
scenario, Jakub is experiencing pain in his right ankle and knee therefore, it
is appropriate to quantify the pain using a scale such as a Visual Analogue
Scale (VAS). In addition to that, aggravating and easing factors determine the
severity and irritability of the symptoms experienced. Lastly, general health
and past medical history (PMH) are part of the subjective because it’s vital to
know if there are any underlying pathologies that could be precautions or
contraindications. The patient having Type 1 diabetes is an example of a
precaution that needs to be considered as it’s a condition that can affect bone healing. Clinical studies indicate that diabetes
delays fracture healing (Jiao, Xiao and Graves, 2015). Type 1
diabetes mellitus and Type 2 diabetes mellitus both increase fracture risk and
have several common features that affect bone including hyperglycaemia and
inflammation (Retzepi and Donos, 2010).

By
the end of the subjective assessment, the physiotherapist gains an
understanding on the severity, irritability, and nature of the symptoms to help
formulate a diagnosis for the patient’s problem. The severity of Jakub’s pain
is moderate as he described the ankle pain being 5/10 on the VAS. Equally
important is the irritability and this relates to how quickly he experiences
the symptoms from an aggravating activity and how they quickly disappear when
an easing factor is implemented. A patient with a high irritability would find
that their symptoms come on with minimal activity and take a long time to
disappear. However, if the time taken to aggravate is greater than the time
taken to ease then the patient will have low irritability like Jakub. This
suggests that the physiotherapist can examine his condition to the point of
pain. Other factors such his PMH can determine the nature of the symptoms
experienced which in turn influences the vigour during the physical
examination.

In
doing so, the physiotherapist gets an understanding of the patient’s perception
of their condition as it highlights the factors that may be contributing to the
source of the symptoms and pain. Additionally, it helps the physiotherapist to
clinically reason what physical assessments will be a priority and limiting the
extent and vigour of their assessment to suit the severity, irritability, and
nature of the initial diagnosis.

The
patient’s main problem is his ankle therefore the primary hypothesis could be a
problem with the gastrocnemius and soleus muscles along with compressed nerves.
To prove the primary hypothesis and consider safety issues, a list of
assessments the physiotherapist must carry out is needed. This is firstly done
through an observation where the patient’s gait as well as posture can be
analysed while using cutches and if incorrect, the physiotherapist can teach
them how to mobilise correctly and safely. Other observations include looking
at the swelling and colour of the patient’s ankle.

Furthermore,
the ROM of the ankle must be analysed followed by the length and strength of
the gastrocnemius and soleus muscles. A light touch/pinprick neurological test
on the common peroneal and tibial nerve must also be carried out. Palpation of
the ankle, gastrocnemius and soleus, the shaft of the tibia and the knee must
be carried out during the examination. Additionally, the active ROM of the knee
joint should be assessed and as the patient feels pain when sitting cross
legged, the muscle strength and length of the sartorius muscle should also be
tested. Lastly, the physiotherapist could assess the accessory movements at
both the ankle and knee joints as well as the muscle length and strength in the
quadriceps.

Regarding
treatment, the physiotherapist will aim for total patient management and this
involves addressing the primary problem of the patient’s condition which is
their right ankle. This suggests that treatment and management should be
applied specifically to influence signs and symptoms that are present such as
pain, joint stiffness, swelling and functional disability. Rehabilitation might
include therapeutic exercises to help restore range of movement, muscle
strength and stabilise joints which is beneficial for the patient because
they’ll be able to go back to doing functional activities such as taking the
stairs and walking to school rather than taking the bus. Education and advice
is another mode of treatment and it involves teaching Jakub how to continue his
rehabilitation at home and coping strategies to manage the ankle pain. As he
also experiences mechanical pain, manual therapy and exercise would be helpful.
For the inflammatory pain the use of RICE, tape, advice, or electrotherapy are
ideal. The pain relieving modality must be applied accurately to an appropriate
joint to produce relief of pain, considering the severity, irritability, and
nature of the condition (Petty 2011).

Prognosis
is the expected outcome of the physiotherapy treatment. The patient in the
scenario would get a good prognosis as the state of his condition is improving
and he’s in his teenage years. More importantly, Jakub is very active in his
school life as he’s part of the school football and basketball teams so he’s
more likely to adhere to exercise prescriptions.

In
summary, this essay has outlined the emphasis of using clinical reasoning
throughout the subjective examination, physical assessment, and
treatment/management process. Additionally, awareness of clinical reasoning
evidently helps the physiotherapist to identify which factors related to the
condition itself and the patient need to be considered. This avoids assumptions
and misdirection about the patient’s condition hence leading to effective
management and lastly, the physiotherapist can also reflect and learn from the
experience. 

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