This past semester has been a tremendous learning experience in terms of clinical insight, between the five days of the ICE and the clinical conference course. There were times during each of our patient cases that I felt significantly more comfortable in working with the patients, as well as times that I felt lost. The biggest challenge that I faced was figuring out how to adjust the methods of taking measurements as we were taught to be possible or Doris Latham to perform. I feel that performing an evaluation on an acutely post-surgical patient is considerably more time consuming and requires much more adaptability and creativity when determining how to get their measurements and perform special tests. Educating the patient regarding gait training and evaluating and correcting deviations made during the training were the easiest aspects of the treatment for me, personally. I feel much more comfortable with my ability to assess and correct a patient’s gait with a new assistive device than I do with figuring out how to measure hip flexion strength in a gravity eliminated position.

The biggest surprise for me about the cases we have covered this semester is how much we are now being taught to deviate from the full examination that we learned just a few months ago. I think that one of the hardest things to overcome was that up until this class, we were taught and graded on our ability to replicate a very strict, very comprehensive examination, and this semester we were critiqued and our grades suffered for not intuitively knowing that this is not necessary. I wish that there had been some more instruction or at least some more leniency for this, because as far as we were aware, my classmates and myself behaved in the manner in which we had previously been instructed. This obviously applies mostly to the first case that we had, because after we received our grades and reviewed the critiques, we realized that there was a discrepancy between what we thought we were supposed to produce and what was actually expected of us, and changed our approach to the group project.

On a related note, I would say that by far the most challenging case for me was the Paula Dean case, and there are several reasons for this. I have never worked with a patient with a burn before, and we have not covered how to work with this population in school to any extent. Also, learning a complex and completely novel special test like the Jebson was made more difficult by the fact that we were not informed that the school already had a prepared kit for performing this test. Because of this, our group set about trying to collect all of the items on our own, only to find out the morning of the second examination day that this already existed, and had been removed from the storage closet.

Aside from the novelty of the patients’ chief complaint, this case was particularly challenging because of the wound healing aspect of her case. While we had briefly covered wound healing in our Modalities class, we had not spoken about burns, and none of us had any concept of how long it takes for a second degree burn to heal. Beyond that, we also had no idea how much a burn patient should be expected to move and strengthen as their wound healed, which made creating a treatment timeline incredibly difficult and more of a guess than an informed decision. As a group, we spent 6 hours together after the second evaluation day together trying to figure out a timeline to agree upon, using many different sources, and still were not confident in the timeline that we established. In hindsight, I think that we have all been taught that the world of physical therapy and the creation of treatment plans was more black and white than it actually is, and this was a very difficult lesson to learn. While it was uncomfortable and confusing to go through this particular case, I think that it was the start of my realization that this semester was about cutting down the full examination that we were initially taught to a more succinct examination that focused on what is probably most relevant to the case at hand.

The three portions of the examination and evaluation that I now feel proficient with include taking history of current condition, accurately assessing the level of assistance required for transitions and transfers, and performing the cardiopulmonary portion of the examination. In terms of the current condition, I feel confident in my ability to ask appropriate questions and follow up questions regarding the mechanism of injury. I also feel that while I may trend toward being overly cautious when assisting a patient with transfers initially, I am able to effectively walk the line between providing them the assistance they require and making sure that they are performing as much of the transfer as possible, while maintaining safety. Lastly, I feel confident in my ability to take cardiopulmonary measurements such as blood pressure, respiratory rate and heart rate. I am comfortable with my hand placement and my body mechanics, at least when the space around the patient is clear. I had an issue with this during the SPI because I did not remove the chair next to my patient prior to trying to take her vitals, but even as I was taking them I was aware of what I should have been doing.

In terms of which aspects of the examination and evaluation I still need to practice, I would say that they are mostly related to adapting my measuring skills to different settings. I found it difficult to “think around” the movement limitations of Doris Latham to be able to figure out what position she and I needed to be in to take goniometric measurements in. This applied to the manual muscle testing, but there was an additional difficulty with those measurements caused by the fact that I still do not feel comfortable with adapting strength measurements for patients who are less than 3/5. I have reviewed the scale under a grade of 3/5 many times but this case made me aware of the fact that I need to review it more, and practice identifying just what are the differences between a 2-, a 2, a 2+, and a 3-.

The third aspect of the exam that I need to continue to work on is taking a history more succinctly. I often find myself continuing down a line of questioning that may not be necessary, but I am afraid that if I do not pursue each question, I may miss some important detail to the patients’ case. I am hopeful that the skill of being able to recognize which lines of questioning to pursue and which only require a short answer will come with time and more exposure to real patients.

Over the course of this semester, I made a conscious effort to be a proactive member of the group, which translated to coordinating meeting times, making a list of things to accomplish during each meeting, and making sure that everyone came to agreement on each decision. I made this decision because in my previous experiences as a member of group projects, I have always played a passive role, which did not result in me being a very active contributor to those project. This semester, I gave my opinion on which special tests and measures I have previously seen used, for instance, with a patient acutely status post hip replacement and a patient who is recovering from a broken ankle. I feel that I was able to provide a different level of insight than my classmates based on my experience as a PTA, though that did not always yield the correct answer.

Overall, I think that my clinical reasoning has dramatically improved since the beginning of this semester, thanks to a combination of the things that I learned during my ICE and everything I learned during CCII. In general, learning that we are able to pick and choose which aspects of the examination and evaluation we feel are necessary to perform has opened up my view of performing an evaluation greatly. Though I have three years of experience as a PTA, and was able to observe a tremendous amount from the PT’s I worked with, I have not observed an initial evaluation since my clinical experience in 2008. And to be honest, I was not aware enough of what it was that I should have been paying attention to at that time, so I feel that that experience was mostly lost on me.

That said, my concept of what takes place during a typical initial evaluation, regardless of the setting, was very limited. So it has been enlightening to get to go through that experience, step by step, with different patient cases, and see not only how the evaluation process itself differs from case to case but also the different ways in which my fellow classmates approach working with these patients. But more than anything, I think that this experience has lead me to understand that I still have an enormous amount to learn about clinical reasoning to be able to identify, analyze, determine the prognosis for a patients issues all in the course of a few minutes, as I will be required to do in just a little over a year. Namely, throughout all three cases I continued to have difficulty in correctly identifying which special tests and measures are best or most necessary for a particular patient, but I believe that this will come with experience. This is daunting, but I am encouraged by the amount that I feel I have improved over just this past semester.