Week 1: Entry 2

Today I met an 7 and half month old girl who had been referred for physio because of her flat head, plagiocephally. She had an obvious plagiocephally, with the left posterior aspect of her head flatter and I also noted slight facial asymmetry. Secondary to her plagiocephally, she also had slight gross motor developmental delay.

I was able to have a more active role in her assessment and although was not asking the questions and leading the examination i was able to also assess her strength, tone, ROM and also did an AIMS assessment of her. I think I communicated well with her mother as I felt more comfortable with the examination process and the facts that needed to be established in the history.

I also was more able to clinically reason in regards to her developmental delay as I am aware of what a normal 7-8mth old baby should be able to do and after assessing her propose possible reasons for the delay. In this case her delay was the result of poor muscle strength through trunk and shoulder girdle and poor endurance.

I then prepared the report for the physio on the assessment which had room for improvement. I am now aware of specific ways to document assessment findings and hope that tomorrow I will get another opportunity to practice writing up reports.