Diagnosis, and Person-Centred Care in a Clinical Setting

Part 1: Patient consultation

This section of the essay will critically reflect on the assessment, diagnosis and person-centred care approach of a patient seen during the author’s first content practitioner clinic. The report will entail a consolidation contemporary research and advise to justify the decision-making during the consultation including the process of clinical reasoning and consultation model used during the consultation process. Similarly, the report will synthesise the guidelines used in managing the patient’s specific problem.

X presented with constant nagging shoulder pain at his right shoulder joint that worsens whenever he engages in any aggravating activities. The pain, that is localised around his right shoulder joint has been presenting for two weeks now. The physical examination involved subjective interviews, observation, range of motion, muscle power, palpation, special tests and special investigation (such as MRI and X-rays). During the subjective interview, the patient reported that the pain exacerbated when working in the kitchen, knitting, working with the computer, riding a bike or driving a car. Appendix 1 provides further information on the patient.

While evaluating the clinical subjective information from the patient, the author adopted various models of communication, including a hybrid model of both Calgary-Cambridge and Pendleton consultation models. According to Mitchell et al (2005), the Pendleton model highlights seven tasks to be achieved during a consultation process. These tasks include identifying the patient’s reason for attendance such as the nature, history and etiology of the problem, their concerns and expectations, identification and selection of appropriate action towards the problem, consideration of other presenting problems, developing a shared decision-making with the patient, developing patient involvement in the management of their condition, developing an effective relationship with the patient and developing an effective use of available to me and resources.

However, one shortcoming of the Pendleton model realized by the author is that it avoids physical examination, which is crucial for the assessment and diagnosis of first contact patients (Milner et al, 2021). Yet, the basis of diagnostic assessments are thorough physical examination and clinical history taking. Similarly, according to Woodward et al (2000), the diagnostic sensitivity of physical examination is 90%. On the other hand, Public Health England (2018) observed that physical examinations involving imaging studies cannot be ignored for differential diagnosis and for the exclusion of arthritic changes of calcific tendinitis. In case the patient has experienced circumscribe persistence pain or circumscribed functional limitation for 6 weeks or more despite the usually adequate physical therapy, it is important to conduct a further imaging study on them or refer them to a specialist (Kilic et al, 2017). Ultrasound scanning is specifically useful in both bone soft tissue assessment and is relatively cheap, even though it is highly dependent on the operator (Artus et al, 2014). Meanwhile, research evidence indicates that when used by experts, ultrasound scanning can help detect rotator cuff tears that have a high sensitivity and specificity rate of 90-100%. It may therefore be useful in diagnosing tenosynovitis and bursitis, even though there is a paucity of evidence for this claim. Meanwhile. As per Artus et al (2014), there is a poor causal link between clinical presentations and imaging findings in primary care. Loeffler et al (2011) conducted a study on the incidence of false positive rotator cuff pathology in MRIs, the authors found that whereas the radiologist preoperative interpretations predicted a 57.9% incidence of rotator cuff pathology, the operative findings revealed a true incidence of only 13.3%. the authors concluded that careful consideration should be given to MRI interpretations to avoid possibly aggravating or unnecessary surgical intervention. As such, the author chose to treat based on symptoms.

Due to the shortcoming of Pendleton model, and the crucial nature of physical examination, the author chose to use the Calgary-Cambridge model as well, which entails five major items of consideration when consulting with a patient (Patel et al, 2017). An interesting component of this model is the requirement that the practitioner must identify and eliminate or manage any negative feelings or stress that the patient presents with because it may contribute to clinical errors (Richardson et al, 2018). Therefore, the author made efforts to clear the patient’s mind through simple activities such as asking the patient to take a deep breath and asking them to take a glass of water. Furthermore, the author sought to understand and address any other issues at work or at home that could cause stress to the patient; and any other potential stress triggers.

Fundamentally, the two consultation models are based on the concept of effective communication between the patient and the practitioner. According to Riva et al (2020) effective communication is a core skill for first contact practitioners because their ability to communicate and establish an interpersonal relationship with the patient determines the accuracy of their diagnosis and treatment. As per Elsodany et al (2018), some of the benefits of effective patient-clinician communication include ensuring that the patient clearly understands all the relevant treatment information (e.g. diagnosis, management pathways), regulating the patient’s emotions, and managing the patient’s expectations, anxieties and fears.

On the same note, Minghelli & Vicente (2019) highlighted the importance of developing a good rapport with the patient. As such, the author began interacting with the patient by greeting him while maintaining an eye contact with him and smiling as I introduced myself and informed my role to her as a first contact practitioner. I also adhered to Yeng et al (2017) ’s suggestions of being a good listener, especially within the first sixty seconds of the interaction. Meanwhile, the first sixty second period during the consultation is important not only for listening but also for allowing the patient to express their problem with minimum interaction. According to Elsodany et al (2018), it presents an opportunity for the practitioner to take note of the patient’s fears, anxieties and concerns. Elsodany et al (2018) supported these assertions but added that the first sixty seconds is crucial for having an uninterrupted attention to the patient because this is the time, they reveal anything relevant to the presenting health condition. In my consultation with Jack, the first 60 seconds presented an opportunity for collecting crucial information about his clinical history and associated symptoms.

An important part of my consultation with X was my ability to actively listen to the patient during the initial stages of the consultation, and this entailed listening to his verbal and non-verbal communication (Kilic et al, 2017). I developed active listening skills through positive consultation outcomes and through learning from mistakes, enabling me to improve my practice. Nonetheless, I used non-verbal communication skill, which entailed sitting two meters away from the patient, in a relaxed posture and good eye contact. I also ensured that I used open-ended questions, allowing the patient to explain and expound his history of the presenting problem, rather than giving yes or no answers. An example of open-ended question that I asked the patient was “what type of pain are you experiencing?” This question prompted the patient to thoroughly explain his feelings and give a better insight into his pain. I concluded the history taking by summarising Jack’s history to allow him to clarify or rectify the information (Patel et al, 2017). similarly, according to Minghelli & Vicente (2019), summarising the patient’s history gives the patient confidence over the practitioner’s capabilities before beginning the physical examination.

A first contact musculoskeletal primary care practitioner must rule out any red flags that suggest a serious pathological complication that might call for urgent medical referral. As per National Institute for Health and Care Excellence (NICE, 2013), the red flags for painful shoulder that call for urgent referral to secondary care or investigation include history of trauma and acute presentation, systemic symptoms such as night sweats, fever, new respiratory symptoms, abnormal joint shape, local swelling or mass, severe restriction of movement or tender joint. Blood tests may therefore be useful in this case to detect the red flags, especially where there is a suspected inflammatory process (Allen, 2018). It is also normal to have radiographs on acute rotator cuffs tears unless it is suspected that there might a greater tuberosity avulsion fracture. It was also useful to diagnose for progressive muscular hypo melanosis, which clinically presents in the form of circular, multiple non-scaly and pale spots (Martinez-Calderon et al, 2019, Lewis, 2011). However, the patient presented with none of these red flags during the consultation.

Prior to conducting the physical examination, I had already considered some red flags such as fever, night sweats, abdominal joint pain, and new respiratory symptoms, because the patient had not complaints concerning them. Furthermore, I build the patient’s clinical risk profile based on his lifestyle, habits and other determinants of health. On this account, the patient had no issues associated with allergies, alcohol and smoking. However, I continued to examine the patient’s right shoulder to rule out any other conditions such as pancreatitis, thoracic outlet syndrome, and cervical referred pain. I ruled out cervical referred pain because the patient did not present with any paranesthesia numbness and subscapularis involvement. Similarly, I ruled out pancreatitis because the patient did not present with any abdominal pain (i.e. upper abdominal pain, abdominal pain that radiates to the back and abdominal pain that worsens after eating) (Rawla et al, 2018, Lewis, 2016). Lastly, I ruled out thoracic outlet syndrome because the patient tested negative for Adson’s Test.

My main hypothesis for the patient’s problem before the objective assessment was rotator cuff-related pain with symptoms of supraspinatus tendon and subscapularis involvement. This hypothesis was specifically based on Nwawka et al (2019)’s assertions that the patient may present with progressive subdeltoid aching that aggravates by elevation, sustained overhead activity or abduction. Furthermore, Nwawka et al (2019) stated that the patient may feel a burning sensation on their shoulder, or tenderness. The pain may also be available on the lateral upper arm or on topand front of the shoulder (Rangan et al 2015). initially, the pain may befelt only during activities but later, it may occur even at rest (May et al 2010). However, I could not be so specific in the diagnosis of shoulder pain and therefore needed a subgroup with non-structural diagnosis. The patient could be suffering from a degenerated supraspinatus tendon as result of repetitive stress and overloading occupational activities (Weiss et al. 2018). At this stage, my clinical reasoning was based on a hybrid pattern of recognition and hypothetic-deductive reasoning where I ascertain some clues about the patient’s presenting problem based on the subjective assessment, then develop certain theories or hypotheses to test during the objective assessment (Patel et al, 2017). But Minghelli & Vicente (2019) observed that many experienced practitioners only use the hypothetico-deductive model when handling patients with complex problems. He further added that clinical reasoning is associated with pattern recognition and therefore it does not require any specific testing. However, I decided to use both hypothetico-deductive reasoning and pattern recognition to avoid neglecting any serious underlying pathological complication, to avoid clinical misdirection and to develop an accurate diagnosis that would help with planning a good treatment management program for the patient (Kilic et al, 2017).

NICE (2013) guidelines recommend various forms of treatment for Rotator cuff related pain with symptoms of supraspinatus tendon and subscapularis involvement including good workplace posture, light duties, and regular breaks in between, educational self-management advise and an effective physical activity program, and if necessary, oral non-steroidal anti-inflammatory drugs (Elsodany et al, 2018). Similarly, the Public Health England (2019) strongly recommends physical activity as an important intervention for the prevention and management of musculoskeletal conditions, especially when the physical activity is combined with patient education. Specifically, for rotator cuff pain, the patent may need physical therapy that focuses on assisted/passive range of motion, immobilization, and progressive resistance activities (Rangan et al 2015). Therefore, I provided X with the guidelines of self-management including education on shoulder anatomy and why he should only take lite duties. To personalize the care to the patient’s job roles, as suggested by Nwawka et al. (2019), I explained to him that he is at risk of injury when he lifts too heavy objects that are either too large or difficult to grasp, when he puts a strenuous effort on any activity, and when the load requires him to bend and twist when lifting (Nwawka et al 2019 et al, 2019; Rangan et al 2015). Thus, I made him understand that he needed to eliminate these risks whenever he would be reasonably able to, and in instances when he is not able to, he should consider an average amount of load that can minimize the risk. Before giving him a brochure containing the above information for his future reference, I advised him to seek help from the emergency department in case he encountered red flags symptoms of severe abdominal pain, as well as any of the systemic symptoms. I reemphasised proper mechanics, flexibility, strength to ensure that he had a good understanding of pathology. I also ensured that he had a good understanding of the prescribed home exercises, especially the strengthening and warm-up techniques. Finally, I asked the patient to immediately return to the hospital for further medical check-up in case the symptoms did not improve, especially one week after completing the oral non-steroidal anti-inflammatory drugs. I ensured I was clear with the guidelines and asked X if he was okay with the guidelines too to foster shared decision-making.

Based on the musculoskeletal core capabilities framework for first contact practitioners (Public Health England, 2018), it is important to promote physical exercise among patients suffering from any musculoskeletal pain. Furthermore, Nice guidelines (NICE, 2013) also recommends the prescription of either specific home-based exercises or referral to a group exercise as first line treatment for patients suffering from musculoskeletal shoulder pains. However, due to the COVID-19 guidelines on physical distance, I prescribed some home-based physical activity. The prescribed physical activity was evidence-based. Weiss et al. (2018) stated that strengthening exercises can be helpful to help work out the shoulder girdle musculatures. Therefore, due to the COVID-19 restrictions, I recommended various home-based exercises that covered the three stage of treatment namely: immobilization, assisted or passive range of motion and progressive resistance exercises. After achieving reduced pain, I prescribed active-assisted mobilization exercises that he could do using an exercise bar. Meanwhile, I prescribed several other strengthening exercises that would keep the shoulder joint stronger and prevent further injuries. Specifically, I advised him to perform side lying external rotation and prone horizontal abduction, all with dumbbell against gravity (Olds and Webster 2021; Littlewood et al 2010).

There is evidence indicating the effectiveness of physical therapy management for Supraspinatus Tendinopathy. According to Minghelli & Vicente (2019), the main aim of physical management is to alleviate pain, reduce muscular wasting, prevent aggravation pain, prevent inflammation and normalize the shoulder girdle’s arthrokinematics. Furthermore, Elsodany et al (2018) recommended strengthening exercises such as isometric exercises that help to work out the shoulder girdle musculatures. Ideally, the management of supraspinatus tendinopathy entails different progressive exercises that can be execute din three phases of treatment namely: assisted/passive range of motion, immobilization, and progressive resistance exercises. But, as per Lähdeoja et al (2020), early management include the avoidance of repetitive movements that aggravate the pain.

Minghelli & Vicente (2019) explored and discussed the association between psychological factors and musculoskeletal pain-related disability and proposed that if the patient is at acute or sub-acute phase of their pain, they should receive other psychological interventions against depression and anxiety. X did not report any case of depression or anxiety and therefore my focus was mainly on addressing the mechanical nature of the patient’s shoulder pain.

Oral non-steroidal anti-inflammatory drugs (NSAIDS) prescription are advised by NICE (2013) for patients presenting with mild to moderate symptoms and if there are not contradictions to these agents. Similarly, according to Elsodany et al (2018), a short-term (7-14 days) use of NSAIDs can be used to relieve pain associated with a tendinitis. However, there is a paucity of evidence supporting a long-term use of NSAIDs for the same purpose (Cardoso et al 2019). Similarly, NSAIDs are not advised for patients with renal compromise because it has been associated with acute kidney injury (Baker & Parazella 2020). While the musculoskeletal core capabilities framework allows first contact practitioners to prescribe NSAID medications, I could not do the same because I am not an independent prescriber. Thus, I recommended that a GP could prescribe Naproxen for Jack. The supervising GP agreed and prescribed Naproxen for Jack. Meanwhile, as part of my learning development plan, I intend to further my studies to reach a level where I could prescribe NSAID medications.

NICE guidelines (NICE 2013) also recommend manipulation for musculoskeletal pain such as shoulder pain as an intervention, but only as part of the physical exercise. However, due to time constraints, my consultation with X only lasted for 20 minutes and therefore I could not offer the manipulation procedure. I therefore advised X to return to the clinic after two weeks if his symptoms will have not improved. In such a scenario, he will be referred to a local physiotherapist for further checkup.

Nonetheless, my limitations as anon-independent prescriber necessitated a liaison with a clinical mentor to prescribe and review Jack’s medication. In future, I plan to enroll for an independent prescriber course as required by Health and Care Professions Council so that I can safely prescribe and enhance my consultation experience with patients.

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Section 2

In this Part of the essay, the author will explore the reason for the patient’s attendance of the consultation and how patient-centered approach was utilized to consider the patient’s mental and physical health needs; while promoting the patient’s overall well-being. Similarly, this section of the essay will explore the underpinnings of the management plan, which includes shared decision-making, understanding patient’s mindset, and improving patient -self-efficacy, and social prescribing when developing a holistic treatment plan beyond the presenting clinical complication.

X is a 67-year-old man visiting a first-contact practitioner clinic for reported shoulder injury. The patient reported constant nagging pain which presented one and a half weeks ago when moving heavy objects at home on the table. Because the patient works in a factory and his job involves lifting, pulling and pushing heavy objects. He is not struggling with activities of daily living and her condition had started worsening. The patient has been diagnosed by painful arc on abduction with click, pain and weakness on resisting subscapularis as well as supraspinatus muscles activity. Multi-factorial causations with poor posture, muscle imbalance (tightness and or weakness) is also a contributor. The patient also has right knee pain diagnosed OA and high BMI/Overweight, so she has been referred to weight management programme, in which she has agreed to participate. She also has mental health issues hence he’s been referred to local mental health services: The Primary Care Network ‘listening and guidance’.

A musculoskeletal assessment on the patient revealed positive results for the Hawkins & Kennedy Test as well as a positive Lift of Test. In the Hawkins and Kennedy Test, the patient’s arm shoulder is placed in 90 degrees flexion with the elbow flexed to 90 degrees and the arm internally rotated. The test is considered positive if the patient feels pain with internal rotation (Buchner et al, 2017). In the Lift of Test, the result is considered positive when the patient is unable to move the dorsum off the back Shafritz et al, 2017). However, further assessment revealed negative results for apprehension test for shoulder stability as well as negative results of SLAP lesion tests. Upper limb Tissue Tension Tests also revealed negative results. Meanwhile, the results of both objective and subjective assessment showed some psychological and social underpinnings contributing to the complications of the patient’s shoulder injury and overweight.

I identified that the cause of the patients’ shoulder injury and overweight was not only attributable to her occupational duties but also to several other social, physiological, and psychological factors with needed to be addressed through a patient-centred approach – based on the Care Quality Commission’s (2014) regulation 9, the NICE guidelines and Musculoskeletal core capabilities framework for first point of contact practitioners. Collectively, these regulations stipulate that first contact practitioners and healthcare providers must partner with the patients through shared decision-making and by considering patient needs.

Therefore, based on my assessment, I decided to address the patient’s psychological and social components that worsened her condition. For instance, I asked the patient about the nature of tasks she undertakes at work and realized that her shoulder pain was contributed by his decision to overwork in search of higher bonuses. On this note, I explained to the patient the importance of engaging in just enough tasks that would give her body a chance to rest. I also explained to her that failure to take care of her health would render her unfit for any piece of work altogether, and this may contribute to other unwanted incidences such a lose of job. I also explained to her the importance of speaking to their HR managers or community social workers in case of any financial needs, rather than overworking and risking her health. The patient later agreed to consult the local community social workers and received the contact address for her local community social workers so that she could consult them and get a more holistic solution to her socio-economic problems.

Meanwhile, the patient also agreed to attend a local physical activity club that would address her physical exercise needs (to address her overweight condition) as well as other personal health needs such as nutrition, hydration, balance, strength, sensory issues and hand care advises. This is in adherence to NICE guidelines (2013), for musculoskeletal injuries among older people above the age of 65 years, whom, according to the guidelines, should receive individualized multifactorial intervention that includes referral for proper medication and thorough assessment.

Because I am not an independent prescriber, I had requested a GP to review the patient’s medication (Naproxen) in the context of her recent shoulder injuries, her socio-economic problems, overweight and work-related problems. According to Elsodany et al (2018), a short-term (7-14 days) use of NSAIDs can be used to relieve pain associated with a tendinitis. I also advised her to book an appointment with her local National Health Service for routine physical health checkup. In the recent assessment, the patient had reported that she would work past the ordinary hours to earn higher bonuses. Therefore, I provided the patient with a booklet on ergonomic health that could guide her on the appropriate physical posture and other safer ways of carrying out manual tasks at the workplace. Nevertheless, from the consultation, I also noticed that the patient had certain characteristics of resilience, enthusiasm and growth mindset that would help overcome her challenges, especially through his positive mindset throughout the consultation session and how responsive he was to our engagement. According to Schroder et al (2017), individuals with growth mindset are more likely to be successful with self-management activities compared to those who lack self-drive and self-efficacy.

Therefore, I felt that having shown these personal characteristics, the patient could easily be motivated to change and adapt to better occupational habits and reduce har risk of repeat shoulder injury. Encouraging patients to take charge of their health through shared decision-making and participation on their health abides by the NHS Five-year Forward View, which seeks to give patients the freedom to choose where and how they would like to receive treatment (The Kings Fund 2014).

References

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