On my current prac I was asked by the nursing co-ordinator to see a patient who was complaining of pain in their (L) UL following a fall. When I saw the patient they stated that it was not pain in their arm that was bothering them, it was that ‘their arm didn’t work’ anymore. The patient reported they had had a fall at home and that ‘they thought’ this was when their (L) UL lost its function. The patient had nil activation and voluntary control around their (L) shoulder, FROM at the elbow, wrist and hand – but significantly weaker compared to the (R) and altered/diminished sensation of their entire (L) palm. Looking at the posture of the UL it did not present like any traumatic injury I had seen, instead it looked very similar to the UL presentation of some CVA patients I had treated. As I was unsure I paged my supervisor who examined the patient and agreed the presentation indicated a neurological event. Adding to this the more we questioned the patient we identified they had a facial droop and had had a period of time where they couldn’t quite remember the events clearly, and it was around the time they fell and these symptoms first presented.

I documented these findings in the notes and began to retrain the function of this patient’s UL (reach, pincher grip, grasp etc). The following day the consultant documented that this patient had torn their RC and ordered an US for that afternoon for confirmation. That same morning the registrar approached me and stated they felt that this was not a RC tear and would like to investigate the possibility of a neurological incident further, but were unable to do so at this stage until the RC tear was ruled out. The US revealed no inflammation of the RC or evidence of an acute injury, it did reveal a tear of subscapularis, but was reported as being due to degerenerative changes (the patient was in their late 80’s). Despite this the consultant wrote for physio to treat the patient’s RC injury. Whilst this didn’t affect my treatment – as I continued retraining reach etc as this was the patient s main functional limitation (nil pain, swelling etc) I did overhear the consultant and registrar having several 'arguments/discussions' in the doctor’s office regarding this particular patient. When I was asked to provide feedback about the patient’s progress etc it was extremely awkward as all the assessment findings and progress the patient had been making indicated a neurological event and not the RC pathology the consultant had diagnosed. In the end a series of neurological investigations were ordered and it was revealed that the patient had had a minor stroke.

I wasn’t sure if the situation was an indication of some negative politics or power play occurring between the consultant and registrar but it did reveal a key issue for me. In the hospital setting as physios we often read the patients notes (prior to seeing them) get the diagnosis and then from there meet the patient and treat them accordingly. In 9/10 this would be appropriate (assuming that you still are doing a clinical examination etc) but this incident really made me realise that when you are treating a patient and their diagnosis doesn't seem to fit with their presentation and response to PT Rx make sure you follow it up. While as physios we don’t have the training and skills as a doctor for diagnosing conditions we do have a fairly good understanding and ability to recognise clinical signs and symptoms of a variety of conditions. Thus this particular situation showed me that we constantly need to be using this skill and analysing if the patient is responding to the PT Rx as they should be, and if they’re not considering the possibility that something else may be going on, and should be followed up. In this scenario the registrar’s actions meant that the patient was entitled to and received a variety of services (which with a RC injury they would not have received) when they were D/C which will hopefully ensure they regain as much function in their UL as possible.