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Subjective examination Amir
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- 2. SUBJECTIVE EXAMINATION Dr. Alam Zeb alamzebamir92@gmail.com
- 3. SUBJECTIVE EXAMINATION Gathering information from the patient and from their medical notes
- 4. QUALITY SUBJECTIVE EXAMINATION Clear communication Speak slowly and deliberately Keep questions short Ask only one question at a time
- 5. RESULTS OF SUBJECTIVE EXAMINATION Source of the symptoms and/ or dysfunction, i.e. the structure(s) at fault Factors contributing to the condition, e.g. environmental, behavioral, emotional, physical or biomechanical Alerts the clinician about further examination Precautions or contraindications to the physical examination Prognosis of the condition How best to manage the patient's condition
- 6. BODY CHART
- 8. TWENTY-FOUR-HOUR BEHAVIOUR OF SYMPTOMS Night symptoms Evening symptoms Morning symptoms
- 9. FUNCTION How the symptoms vary according to various daily activities Detailed information on each of the daily life activities is useful in order to determine Structure(s) at fault Identify clearly the functional restrictions
- 10. STAGE OF THE CONDITION Knowing whether the symptoms are getting Better Worse Remaining static
- 11. GENERAL QUESTIONS Special questions General health Weight loss RA Drugs Steroids Anticoagulants X-ray Cord symptoms Dizziness
- 13. SPECIAL QUESTIONS FOR LUMBAR SPINE Cauda Equina (compression of the spinal cord that could lead to serious long term damage to the cord unless treated immediately) Any bladder or bowel dysfunction Bilateral neural symptoms in both legs Perineum numbness/pins and needles Unremitting pain
- 14. SPECIAL QUESTIONS FOR CERVICAL SPINE Signs of some Cervical Arterial Dysfunction, upper cervical instability, disease of inner ear 5 D’s Dizziness Drop attacks Dysphagia (swallowing problems) Dysarthria (speech problems) Diplopia ( Double vision)
- 15. HISTORIES History of the present condition (HPC) How long the symptom has been present Whether there was a sudden or slow onset of the symptom Past medical history (PMH) Details of any medical history(THREADS) History of any previous attacks Results of any past treatments Social and family history (SH,FH) Age of the patient Employment Home situation Dependents
- 16. Subjective Examination Body Chart Type & area of symptom Depth Quality Intensity Abnormal Sensation Relationship of Symptoms Behavior of Symptoms Aggravating factors Easing Factors Severity & Irritability 24 hrs behavior Daily Activity Stage of Condition Special Questions General Health Drugs Steroids Anticoagulants Weight loss – recurrent unexpected Rheumatoid Arthritis Spinal Cord Cauda equina symptoms Dizziness X-ray (recent) History of Present Illness How it started? Past Medical History Relevant Medical History Previous Attacks Effects of previous treatments Social & Family History Age Gender Home of work situation Dependents Leisure Activities
- 17. SUMMARY OF SUBJECTIVE EXAMINATION
Editor's Notes
- Subjective Examination in Physiotherapy This article will discuss the subjective examination for physiotherapists in terms of what to ask and why we ask these questions in the clinical reasoning process. We use the subjective assessment in order to assess the biopsychosocial context of the patients current pain state. What this means, is that when we gather our subjective information, we are not just thinking about the source of pain in terms of a pathological process, but also how the persons social and psychological state is affecting there pain.This leads us into our objective examination with a working hypothesis of what factors may be contributing to the persons pain and therefore what tests are more of a priority when physically assessing along with helping us clinically reason what we are doing with the patient and why.It is very important to asterisk your main subjective findings so that you can use these subjective markers as you treat the patient on following visits in order to measure progress.What follows is a list of a subjective exam which is by no means an exhaustive list but covers the main areas you need to discuss and more importantly why you are asking questions in each section.Before we start i will give a list of red flags for serious pathology. These are discussed throughout the article but i think its important to be aware of these things as you go through the assessment. This enables you to have your radar raised for serious pathology that may need an onward referral. You are looking for an abnormal pattern which includes some of the red flags and doesn’t seem like something that physio is appropriate for. Obviously a lot of patients will have some of the red flags and the findings should be taken in the context of the complete clinical picture before an onward referral is made.RED FLAGSUnexplained weight lossConstant unremitting painOver 55 years old or under 20Widespread neurologyPast history of cancerTraumaThoracic pain without obvious causeCauda equina symptoms (see bottom of article)CAD symptoms (see bottom of article)The following is a general guide as to how i flow through my exam but as long as you get all the info, do it in any order that suits you.HPC (history of present condition) – Firstly you want to find out the history of the present condition1. How long have they had the pain for?This gives you an idea of whether they are in an acute phase or a chronic state and what stage of healing they may be in if you are hypothesising a soft tissue/bone injury (obviously these stages overlap)2. When did it start? MOI (mechanism of injury)/ insidious?This will tell you if there was a form of trauma which should always give you suspicion of a fracture if they have not had any scans. It will also give you an idea of possible tissues that may have been stressed during the trauma based on the direction of trauma and force/speed of trauma.3. Did your life circumstances or activity levels change at this time?This gives an indication of any stress at this time or possible overload due to increasing training etc4. Is the pain getting better, worse, static or episodic since it started?This will indicate the state of the pain state and pain that is getting worse will generally take longer to recover from than pain that is progressively improving. Also if the pain is episodic you can try to establish patterns of movement or behaviour around these times to see if certain situations increase and reduce the pain5. Have they seen anyone about the current episode of pain?This will indicate whether they have seen there GP and give you info as to whether any scans have been taken which can be very useful in situations of trauma to rule out fractures and/or soft tissue ruptures/tears. It will also tell you if they are under the care of any consultants and give you insight into there current direction of treatment. It is also useful in talking about what they have been told by other professionals as this can have a big impact on there psychological/emotional state with regards to the pain.6. Have they had the same problem before and if so how was it treated?This gives valuable info into whether their problem keeps repeating itself which gives an indication that they are not getting to the bottom of their problem with previous treatment. It also gives an indication of treatments that may have worked for the patient recently and also ones that have not worked and gives you an insight as to what sort of treatment the patient expects and whether some education may be necessary as part of the patients treatment plan.PC (presenting condition) – Discuss the symptoms as they present now 1. Body chart/location of pain?The location of the pain will give an indication of the possible sources of pain through structures directly beneath the site of pain and also structures that refer into that area of pain. If you have multiple areas of pain you will also gain info on how each area interacts with the other which will either implicate one structure causing the pain or multiple structures causing the different areas of pain. Asking which pain is the worst can direct your assessment in situations where a patient has multiple sites of pain.2. What is the Quality of pain?This can give you some indication of the nature of pain but you must be mindful that this is very subjective and can be misleading. Some proposed areas relating to quality of pain is below:Bone = Deep, nagging, dullMuscle= Dull acheNerve root= sharp shooting, electric shockSympathetic= Burning, pressure, stingingVascular= Throbbing diffuse pain3. What is the intensity of pain? (use VAS or NRS)You can use the VAS for this but i generally use the NRS (numerical rating score from 1-10). This will give you an idea how severe the pain is at present which will guide your objective assessment. It gives you a good subjective marker that you can return to in future sessions in order to chart progress.4. Is it constant or intermittent?Constant pain which does not change must be viewed with caution as this is a red flag for malignancy and/or metabolic disease. Pain which is constant but varies in intensity and allows sleep although possibly disturbed is a sign of inflammation. Pain which is intermittent in nature in that it is only there on certain movements suggests a mechanical source of pain and pain that is intermittent which increases as an activity is carried out is indicative of ischaemic postural type pain.5. Is there reffered pain or any Pins and needles/numbness?Pain which refers a long way from the site of pain does suggest some nerve root irritation, Pins and needles and/or numbness is a definite sign that the nerve root and/or peripheral nerve is involved although this could also be caused by vascular disorders like diabetes so this must be taken into acount. Pain that is reffered a long way from the source of pain suggests more severity than pain which is quite local to the source of pain.6. What are the Aggravating factors?This gives you insight into what positions/movements/behaviours/feelings make the pain better and worse and will then indicate certain structures that may be at fault for the pain. This is a great time to determine the irritability of a pain state. If the pain is brought on quickly and takes a while to settle this would indicate an irritable condition. One which comes on and then goes immediately on cessation of an activity would generally be said to be low irritability. Obviously there can be different combinations of this and also different movements may be more or less irritable. This will guide your physical exam as for a condition that is highly irritable you may want to do the test in a specific order as once the pain has been aggravated you are more likely to get a lot of false positives with certain tests. It also gives you an indication of the relationship between symptoms as you can determine if painful sites come on together or separately with the same activities. You can also ask about commonly known positions of aggravating positions such as below:TMJ – Yawning, chewing, talkingC-spx- Reversing car, sitting, readingT-spx- Deep breathL-spx- Sitting, standing, bendingSIJ- Standing on one leg, turning in bed, getting out of bed, walkingHip- Squat, walking, stairsFoot/ankle- Walking, running* Make a note of how symptoms affect functional activities.7. What eases the pain?Gives you an indication on irritability and confirms relationship between pain. Does painkillers reduce the pain if so what type? This may give you an indication as to the type of pathology going on.8. What is the 24 hour pattern of pain?Night symptoms – joints have less force in lying so should be less painful in such conditions. Ask what position is most comfortable. It is common to be woken with pain as turning in sleep may aggravate symptoms but constant night pain that gives no ability to sleep should be viewed with caution of malignancy. Ask about pillows if a C-spx problem plus firmness of mattress in spinal patients can be useful information.Morning symptoms – Morning pain with minimal improvement suggests inflammation. Pain in AM which gets slightly better with movement but worse as the day goes on is linked to OA.Increasing through day suggests some postural type pain so need to find out what they are doing during the day that seems to be causing the increasePMH (Past Medical History/Screening questions)1. Is your general health at present good? No unexplained weight loss? Constant night Pain? Gait disturbance?Gives you an idea of if they feel unwell which could indicate systemic or metabolic problems. Unexplained weight loss, constant night pain and gait disturbance/coordination issues are all signs of possible malignancy or serious pathology that would require referral.2. Ask about THREADS (Thyroid, Heart, Rheumatoid, Epilepsy, Asthma/Respiratory, Diabetes, Steroids)Thyroid problems are assosaited with increased neuromuscular issues such as frozen shoulder and dupytrens plus carpal tunnel. You also want to know if this is controlled.Heart problems may give you an indication of how good the circulatory system is so may flag up vascular issues that could contribute to the pain plus if a pacemaker is fitted this will limit some treatments that you can do as it is a contraindication so is important info to obtain.Rheumatoid or inflammatory joint disease may be a causative factor in the pain but may not. Avoiding accessory motions to the C-spx and care with other joints is indicated in these patients as this can flare up symptoms.Epilepsy is something you want to be aware of in case of a fit and find out if it is controlled plus what type of epilepsy so you know if there is a likeliness of a fit or not.Asthma you want to find out if it is controlled plus if problems are around thorax some breathing strategies may be helpful in terms of not aggregating the symptomsDiabetes is associated with poor healing and peripheral neuropathiesLong term oral steroid use has been associated with osteoporosis, skin quality is often reduced so taping need to be careful and handling needs to be done with care.3. Any history of Cancer?Pain associated with current malignancy might not be relevant for physiotherapy, history in the family or with the individual may raise your suspicion levels if other red flags are present.4. Previous surgery?This gives you an idea of previous medical issues they may have forgot about (you would be surprised how often this happens) also gives an indication of previous injuries. Hysterectomies have also been linked with osteoporosis.5. Previous fractures?Gives an indication of possible weak points in the patients system plus previous injuries6. Osteoperosis/bone disease?This gives you info on bone strength which is important in treatment as you may want to avoid manipulations and handle with more care when/if doing manual therapy7. Pregnancy?If the patient is getting pelvic girdle pain this could be due to pregnancy. You also want to be careful as in the first trimeter there is increased risk of miscarriage so certain treatments may be contraindicated at this stage.Special Questions for Lumbar spine and C-spxL-spx Cauda Equina (compression of the spinal cord that could lead to serious long term damage to the cord unless treated immediately)Any bladder or bowell dysfunctionBilateral neural symptoms in both legsPerineum numbness/pins and needles/strnage sensationsUnremitting painC-spx signs of some Cervical Arterial Dysfunction, upper cervical instability, disease of inner ear (possibly cranial nerves – Look up my cranial nerve testing article)DizzinessDrop attacks (feinting feeling like your going to faint)Dysphagia (swallowing problems)Dysarthria (speech problems)Diplopia ( Double vision)DH (Drug history)Are they on any medication?Gives you an indication of health issues, Anticoagulant therapy patients need to be handled with care. If they have been prescribed pain meds then its important to know what type and if they are helping. Long term pain meds can cause addiction and need to be aware of the psychological aspect that this causes in a pain state.SH (social history)1. What do you do work wise?This will give an indication of general postures adopted during the day and the affect this has on the pain2. What activities/sports/hobbies do you do outside of work?Gives an indication of activity levels, can determine if is able to do current levels outside of work or if unable.Couple of important questionsWhat do they think is going on?We are often quite perceptive about what is going on in our bodies and its sometimes useful to get the patients perspective on whats happening. Also gives you an insight to their state of mind about the issue.What are you expectations?Its often helpful to get the persons expectations of physio treatment and also about the treatment. Some patients will need more education than others and some expectations will need to be revised at times when these expectations are not helpful to their pain state e.g. when a patients perception is they need to stay still to prevent their back pain, we know this is not true so need to educate them. Peripheral joint questionsYou can also ask about swelling, clicking, grinding, giving way and locking which is especially important in the knee where true locking where the patient cannot move the leg is a sign of a bucket handle meniscal tear which needs onward referral.So there you have it, a pretty comprehensive look at the subjective assessment and how to interpret the questions you are asking so you don’t just ask the questions, you actually know why you are asking them and what to do with the answers. Obviously there are other questions that can be asked but if you go through the list here and get confident and comfortable you won’t go far wrong.
- By the end of the subjective examination the clinician needs to decide Oones 1 994): • the source of the symptoms and/ or dysfunction, i.e. the structure(s) at fault • what factors are contributing to the condition, e.g. environmental, behavioural, emotional, physical or biomechanical • whether there are any precautions or contraindications to the physical examjnation • the prognosis of the condition - this can be affected by factors such as the stage and extent of the injury as well as the patient's expectation, personality and life-style • how best to manage the patient's condition