Post-Session Dizziness, a Large Bruise, and a Changing Mole

Triage the dizziness first - it is the finding most likely to be dangerous.

Ask, in this order:

1. Right now: are you dizzy sitting down, or only when you stand? Have you actually fallen or fainted? Is there chest pain, palpitations, breathlessness, slurred speech, one-sided weakness, or a severe headache? Any of these means emergency services now, not a phone chat.
2. Hypoglycaemia screen: sweating, shakiness, hunger, confusion, blurred vision, palpitations. She is on insulin and skipped her afternoon snack, and the session came after that - this is a plausible cause of the standing-up dizziness. Advise her to check her blood glucose if she has a meter, and if it is low or she cannot check, take 15 g of fast-acting carbohydrate and recheck in 15 minutes.
3. Blood pressure and medication timing: did she take losartan and her insulin as usual? Does she monitor at home? Orthostatic dizziness is common with antihypertensives, and a warm room plus vasodilation from massage can compound it.
4. The bruise: is it spreading, tense, hot, or painful out of proportion? Any new leg swelling or calf pain? Warfarin plus deep tissue work means bruising is expected but must still be tracked. A tense, expanding swelling or pain in a calf is a same-day medical review, not a Friday appointment.

Advice on the call: sit or lie down, rise in stages, drink water, do not drive while dizzy, eat something. Cold pack to the bruise for 10–15 minutes, wrapped, not direct ice; no heat, no alcohol, no vigorous rubbing of the area. If the dizziness persists at rest, recurs on standing, or comes with any of the red flags above, contact her physician or go to the emergency department today.

On Friday: not until she has been medically reviewed if the dizziness has not fully resolved. If she is symptom-free and her physician is comfortable, a shorter, lighter session is reasonable.

Documentation for the call - a telephone encounter note plus a post-treatment incident entry.

• Date and time of call, client identifiers, and that the call was initiated by the client.
• S (subjective): Reports 8 cm bruise on left thigh after yesterday's 60-minute deep tissue; dizziness on standing after the session, had to sit down; ate lunch but skipped afternoon snack; medications insulin, metformin, losartan, warfarin.
• O (objective, from the call): No report of chest pain, breathlessness, fainting, speech or weakness changes at the time of the call [record exactly what she said and what she denied]. Whether she had checked blood glucose, and the reading if given. Description of the bruise as she described it.
• A: Post-treatment dizziness and bruising - possible orthostatic hypotension, possible hypoglycaemia, bruising consistent with anticoagulant therapy plus deep pressure. Not diagnosed by the therapist.
• P: Advice given (rise slowly, hydrate, eat, cold pack, no heat or alcohol, no driving while symptomatic); red flags listed; advised to contact physician if not resolved or if worsening; Friday session deferred pending review; follow-up call agreed for [date]; therapist signature and time.

Documentation for the mole - descriptive, measured, non-diagnostic.

Use the same objective language a dermatologist would need to see change over time:

• Site: right scapula.
• Size: approximately 12 mm at the widest point (previous note: 6 mm eight months ago - record both, with dates).
• Shape: irregular/asymmetric border.
• Colour: dark, with uneven colour across the lesion.
• Elevation, surrounding skin, any bleeding, itching or crusting - record only what you observed and what she reported.
• Client statement: 'been meaning to see someone about it.'
• Action: advised to have it assessed by a physician or dermatologist; no diagnosis offered; written note given.
• Do not write 'suspicious for melanoma' or 'looks benign.' Write what you saw and what you recommended.

Why this matters: you are not the diagnostician, but you are a witness with a dated record. If it is later found to be something serious, the note shows you observed, measured, recorded and referred, and that you did not reassure her that it was nothing.

Pre-session conditions before Friday is confirmed

• She reports no dizziness at rest or on standing for at least 48 hours, and has been reviewed by her physician if the dizziness persisted beyond the day of the session.
• She has eaten within the previous two hours, has taken her medications as prescribed, and has checked her blood glucose if she monitors at home.
• Ask her to report her most recent INR if she knows it - you are not interpreting it, but a high INR is a reason to be gentler and to ask her to check with her physician.

Session plan

• Length: 45 minutes rather than 60; do not stack a long session onto a hot room and an empty stomach.
• Pressure: light to moderate. She has atrial fibrillation and takes warfarin, so deep tissue over the legs and back is not appropriate as a routine. Work within comfort and expect bruising at lower pressures than other clients.
• Skip the bruised thigh until it has fully resolved - no direct work, no friction, no heat over it.
• Positioning and rising: finish with her seated on the edge of the table for a minute or two, feet flat, water offered, before she stands. Do not let her swing off the table and walk out.
• Environment: not too warm; ventilate; avoid a long hot shower afterwards.
• Monitoring: check in on how she feels at the midpoint and at the end, and record it.

Education to give, in her terms

1. Bruising: with warfarin, bruises happen more easily and last longer. Cold pack wrapped for 10–15 minutes in the first 48 hours, no heat, no rubbing, no alcohol. See a doctor if the bruise becomes tense, hot, rapidly expanding, or if she has a fall or a knock to the head.
2. Dizziness: stand up in stages, hold something, and do not drive if she feels unsteady. If it happens again with chest pain, palpitations, breathlessness or fainting, call emergency services.
3. Blood sugar: do not book a session on a skipped meal; bring a snack. Know her hypoglycaemia signs.
4. Medication honesty: tell every therapist she sees that she is on warfarin - it changes what they can safely do.
5. The mole: hand her a written note with the measurements and the recommendation to see a dermatologist. Follow up at her next visit: 'Did you get that looked at?' Record her answer.
6. Booking: shorter sessions with a gap, not back-to-back deep tissue.

Documentation: the session parameters used, her response, the education given, and the follow-up on the mole referral.