STARES 2 Assessment

S- A 30 year old female patient presented to the private practice complaining of upper thoracic pain referring down right arm which started 2 days ago. She had no referral and was a new patient to the clinic, so I had no information on her prior to our appointment.

T- My task was to do an initial assessment including subjective and objective assessment of cervical spine, thoracic spine and shoulder. Also including a neurological assessment and one of muscle strength. Followed by an initial treatment relevant to my assessment findings and astrix sign and then briefly a treatment plan for further interventions, allowing room for change depending on the patients condition and how it progresses.

A- I began my subjective history examination by asking where the patient’s pain was exactly and if they can describe how it feels and the pain level that it is at best and worst. I then followed my questions to discover aggravating and easing factors and how long it takes to come on and ease. The next questions were 24 hour activity and establish the irritability and severity. Continuing the assessment with special questions and PMHx and HPC. I began my object assessment by assessing AROM shoulder, cervical spine and thoracic spine giving me the ability to rule in or out as a source of symptoms. I added overpressure to all movements and then assessed patient’s functional tasks. This then was followed by palpation of soft tissue and spinal processes. Then I assessed neural tissues as a possible source of symptoms doing neural dynamic tests followed by neural integrity tests.

R- In the subjective history I discovered the patient was washing hair and felt as if pulled upper back and has never done anything like this before. Her general health is good and has no yellow flags. Pain was a constant ache ranging from 8/10 down to 3/10. Patient was mildly irritable on palpation. She had no PMHx of upper back pain, shoulder pain or referred arm pain. She had good general health and is on no medication except panadol for the pain. The result of the objective assessments was that there was decreased ROM in thoracic spine with tender on palpation T2-7 centrally and unilaterally on the right, with T345 referring pain into the arm. Also overactive soft tissue with trigger points in upper traps, rhomboids and subscapularis. Negative neural dynamic test and neural integrity tests were found.

E- I think that I thoroughly assessed this patient as I was able to discover the asterix sign, in which i could target my treatment around. Howeve,r I think that I can still improve on how smooth everything runs and how to keep the assessment on track without seeming rude and cutting the patient off.

R- I think that I can:
-revise proformas
-do as many assessments as I can
-practice, practice, practice
Also keeping up with my evidence based practice for current treatments initially and examinations that are able to correctly diagnose patients.