Goniometry Y1S2 case & reflection
The flow of goniometry assessment is fluid and accurate; I explained the result to the patient, makes him feel safe and secure as in fact the student played my patient do have stiff calf. Other goals achieved include palpation on bony landmarks which were completed in short time with accuracy, the session completed on time while meeting all goals required in the process.
However, improvement would be needed for next video. One of the main objectives to practice for next video would be the plinth height. Since last semester I often misjudge the height and distance needed to provide practice, especially form the plinth. Although in the session I often comes with immediate adjustment for the outstanding distances, but the session would be smoother without environment disturbance. Body posture while building rapport also important, I would place chairs to adjust speaking posture and height during different part of the session.
My patient also suggested he would like to receive more emotional input during introduction, also speed up speeches in general.
Overall, the flow and accuracy for goniometry were met. The goals for next video would be:
1. Plinth height and distance control for treatment
2. Fine tune body posture and talking speed
3. More emotion input
SOAPIER report
S) Anthony Leong(M), age 24, University student
Right ankle injury from basketball training 4 days ago, swelled slightly(reduced).
Mild pain at rest (2/10) and on movement (3-4/10), over lateral area of ankle and foot. Unable to FWB. Running and jumping restricted, unable to drive or walk long distance. Unable to participate in basketball, attending classes and pizza delivery job.
O) AROM / PROM measured
A) Right soleus length reduced, restricted ankle dorsiflexion.
P) Provide lengthening right soleus exercise. Dorsiflexion with flexed knee. Patient support body with edge of bed, or any sturdy item. Slowly bend knee while keeping the heels on the ground, until he feels a pull from soleus. Hold 10-30 sec, repeat 3-5 times a day.
I) The level would gradually increase to similar to unaffected ankle, the patient would be able to feel a pull at the back of his right soleus muscle.
E) Able to control down phase of exercise to tolerable level. No additional pain created, no numbness, not discovered loss of length at other muscle groups. Patient able to hold 10-15 seconds, supported by edge of bed.
R) Patient is willing to continue exercise for 3 times daily, hold 15-30 seconds. Revisiting in 2 days to check on recovery and reassess ROM.
Infographic Resources
