Here's a comprehensive outline and the beginning of a 3000-word description on the **subjective assessment of clinical patient history**. This introduction sets the tone and direction of the full write-up, and I can continue the rest upon your request: --- **Subjective Assessment of Clinical Patient History** **Introduction** In clinical practice, understanding the patient's health status starts with a thorough and systematic approach to subjective assessment. Subjective assessment refers to the information gathered from the patient through communication—what the patient says, feels, or reports. It forms the cornerstone of a healthcare provider’s diagnostic and therapeutic process. Unlike objective data—which includes measurable findings like vital signs, laboratory tests, or imaging—the subjective assessment delves into the patient's personal experience of illness, pain, and dysfunction. The goal is to understand the impact of the condition on the patient’s daily life and to form a holistic clinical picture that guides further examination and treatment planning. The process involves active listening, critical thinking, and empathetic communication. A clinician must not only gather facts but also establish rapport and trust. The patient's narrative helps prioritize the clinical reasoning process and sets the stage for physical examination and investigations. --- ### **1. Importance of Subjective Assessment** Subjective assessment is crucial because: * It often reveals the primary concern that brought the patient to seek care. * It helps formulate a differential diagnosis. * It guides the focus of physical examination and diagnostic testing. * It aids in building a therapeutic relationship. * It uncovers psychosocial factors affecting the condition (e.g., stress, lifestyle, work environment). An accurate and detailed subjective history can prevent misdiagnosis, unnecessary testing, and delayed treatment. In many cases, the diagnosis is strongly suggested by the history alone. --- ### **2. Key Components of Subjective Assessment** A structured approach to the clinical history typically includes the following components: #### A. Patient Demographics * Name * Age * Gender * Occupation * Marital status * Ethnicity (when relevant to disease patterns) #### B. Chief Complaint (CC) The chief complaint is the primary symptom or reason the patient presents. It is documented in the patient's own words. Example: "I have had chest pain for the past three days." #### C. History of Present Illness (HPI) This is a detailed account of the current problem, elaborating on the chief complaint using the **OPQRST** or **SOCRATES** mnemonics: * **Onset** – When did the symptoms start? * **Provocation/Palliation** – What makes it better or worse? * **Quality** – What is the nature of the symptom (e.g., sharp, dull)? * **Region/Radiation** – Where is the symptom located? Does it spread? * **Severity** – How bad is it (often using a scale of 0 to 10)?

1. SUBJECTIVE ASSESSMENT:

2. Objectives
at the end of this lecture the students should be
able to record:
 Chief complain
 Present illness
 Past medical history
 Systemic enquiry
 Family history
 Drug history
 Social history
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3. Physical examination
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4. What is subjective assessment ???
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5. Components of history
 The present complaint
 The history of the
present complaint
 Remaining questions
of abnormal system
 Review of systems
 Past medical history
 Past surgical history
 Drug history
 Immunizations
 Family history
 Social history & habits
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6. Importance of history taking
 Obtaining an accurate history is the critical first
step in determing the etiology of a patient
problem
 it direct the therapist assess a particular area
 It also direct that what type of assessment
should be carried out
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7. General Approach
 Introduce yourself.
 Note – never forget patient names
 Create patient appropriately in a friendly relaxed way.
 Confidentiality and respect patient privacy.
 Try to see things from patient point of view.
Understand patient underneath mental status, anxiety,
irritation or depression. Always exhibit neutral
position.
 Listening
 Questioning: simple/clear/avoid medical terms/open,
leading, interrupting, direct questions and
summarizing
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8. Taking the history & Recording
 Always record personal details:
NASEOMADR.
 Name,
 Age,
 Address,
 Sex,
 Ethnicity
 Occupation,
 Religion,
 Marital status.
 Date of examination
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9. Complete History Taking
 Chief complaint
 History of present illness
 Past medical /surgical history
 Systemic review
 Family history
 Drug /blood transfusion history
 Social history
 Gyn/obs history.
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10. Chief Complaint
 The main reason push the pt. to seek for
visiting a physician or for help
 Usually a single symptoms, occasionally more
than one complaints eg: chest pain, palpitation,
shortness of breath, ankle swelling etc
 The patient describe the problem in their own
words.
 It should be recorded in pt’s own words.
 What brings your here? How can I help you?
What seems to be the problem?
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11. Chief Complaint
Cheif Complaint (CC):
 Short/specific in one clear sentence communicating
present/major problem/issue. As:
 Timing – fever for last two weeks or since Monday
 Recurrent –recurring episode of abdominal
pain/cough
 Any major disease important e.g. DM, asthma, HT,
pregnancy, IHD:
 Note: CC should be put in patient language.
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12. History of Present Illness - Tips
 Elaborate on the chief complaint in detail
 Ask relevant associated symptoms
 Have differential diagnosis in mind
 Lead the conversation & thoughts
 Decide & weight the importance of minor
complaints
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13. History of Present Illness - Tips
 Avoid medical terminology & make use of a
descriptive language that is familiar to them
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14. Pain (OPQRST)
Position/site
Severity – how it affects daily work/physical activities. Wakes
him up at night, cannot sleep/do any work.
Relationship to anything or other bodily function/position.
Radiation: where moved to
Relieving or aggravating factors – any activities or position
Quality, nature, character – burning sharp, stabbing, crushing; also
explain depth of pain – superficial or deep.
Timing – mode of onset (abrupt or gradual), progression
(continuous or intermittent – if intermittent ask frequency/
nature.)
Treatment received or/and outcome.
Onset of disease
Are there any associated symptoms? .
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15. Past Medical /Surgical History
 Start by asking the patient if they have any medical problems
 IHD/Heart Attack/DM/Asthma/HT/RHD, TB/Jaundice/Fits :E.g. if
diabetic- mention time of diagnosis/current medication/clinic check up
 Past surgical/operation history
 E.g. time/place/ what type of operation.
 Note any blood transfusion / blood grouping.
 H/O dental extractions/circumcision & any exessive bleeding during
these procedures.
 History of trauma/accidents
 E.g. time/place/ and what type of accident
 Any minor operations or procedures including endoscopies, dental
interventions, biopsies.
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16. Drug History
 Drug History (DH)
 Always use generic name or put trade name in
brackets with dosage, timing &how long.
 Example: Ranitidine 150 mg BD PO
 Note: do not forget to mention:
OTC/Vitamins/Traditional /Herbal medicine &
alternative medicine as cupping or acupuncture.
 Blood transfusion.
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17. Drug History
 bd (Bis die) - Twice daily (usually morning and night)
 tds (ter die sumendus)/tid (ter in die) = Three times a day
mainly 8 hourly
 qds (quarter die sumendus)/qid (quarter in die) = four
times daily mainly 6 hourly
 Mane/(om – omni mane) = morning
 Nocte/(on – omni nocte) = night
 ac (ante cibum) = before food
 pc (post cibum) = after food
 po (per orum/os) = by mouth
 stat – statim = immediately as initial dose
 Rx (recipe) = treat with
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18. Family History
 Any familial disease/running in families e.g. breast
cancer, IHD, DM, schizophrenia, Developmental
delay, asthma, albinism.
 Infections running in families as TB, Leprosy.
 Cholera, typhoid in case of epidemics.
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19. Social History
 Smoking history - amount, duration & type.
 A strong risk factor for IHD
 Alcohol history - amount, duration & type.
 Occupation, social & education background, ADL, family
social support& financial situation.
 Social class.
 Home conditions as:
 Water supply.
 Sanitation status in his home & surrounding.
 Animals / birds in his/her house.
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20. Social History: smoking
 The most important cause of preventable diseases.
 Smoking history - amount, duration & type.
 Amount: pack”year calculations.
 Duration: continuous or interrupted.
 Any trials of quitting & how many.
 Deep inhalation or superficial.
 Active or passive smoker.
 Type: packs, self-made, Cigars, Shesha , chewing etc.
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21. Social History: smoking
 Ask the smoker whether he is willing to quit or not.
 Do not forget to encourage the smoker to quit
whenever contacting a smoker as it is proved to
increase quitting rate.
 If he is willing to quit, but can not, help him by NRT
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22. Social History: alcohol.
 Note: Do not advice patients or
individuals , to drink for health, because
of:
 Religious & cultural reasons.
 Possibility of addiction with its known
health problems.
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23. Other Relevant History
 Gyane/Obstetric history if female
 Gravida, para, abortions, SZ sections, antenatal care
& screens as for Hep B & C.
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24. Other Relevant History
 Immunization if small child
 Note: Look for the child health card.
 Note:
 If small child, obtain the history from the care giver.
Make sure; talk to right care giver.
 If some one does not talk to your language, get an
interpreter(neutral not family friend or member also
familiar with both language). Ask simple & straight
question but do not go for yes or no answer.
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25. System Review (SR)
This is a guide not to miss anything
Any significant finding should be moved to HPC or
PMH depending upon where you think it belongs.
Do not forget to ask associated symptoms of PC with
the System involved
When giving verbal reports, say no significant finding
on systems review to show you did it. However when
writing up patient notes, you should record the systems
review so that the relieving doctors know what system
you covered.
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26. System Review
General
•Weakness
•Fatigue
•Anorexia
•Change of weight
•Fever/chills
•Lumps
•Night sweats
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27. System Review
Cardiovascular
•Chest pain
•Paroxysmal Nocturnal Dyspnoea
•Orthopnoea
•Short Of Breath(SOB)
•Cough/sputum (pinkish/frank blood)
•Swelling of ankle(SOA)
•Palpitations
•Cyanosis
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28. System Review
Gastrointestinal/Alimentary
•Appetite (anorexia/weight change)
•Diet
•Nausea/vomiting
•Regurgitation/heart burn
•Difficulty in swallowing
•Abdominal pain/distension
•Change of bowel habit
• melaena,
•Jaundice
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29. System Review
Respiratory System
•Cough(productive/dry)
•Sputum (colour, amount, smell)
•Haemoptysis
•Chest pain
•SOB/Dyspnoea
•Tachypnoea
•Hoarseness
•Wheezing
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30. System Review
Urinary System
•Frequency
•Dysuria
•Urgency
•Hesitancy
•Terminal dribbling
•Nocturia
•Incontinence
•Character of urine:color/ amount (polyuria) &
timing
•Fever
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31. System Review
Nervous System
•Visual/Smell/Taste/Hearing/Speech problem
•Head ache
•Fits/Faints/Black outs/loss of consciousness(LOC)
•Muscle weakness/numbness/paralysis
•Abnormal sensation
•Tremor
•Change of behaviour or psyche.
•Pariesis.
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32. System Review
Musculoskeletal System
•Pain – muscle, bone, joint
•Swelling
•Weakness/movement
•Deformities
•Gait
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33. Subjective Assessment
 Main Problem
 Pain
 Stiffness
 Giving way
 Instability
 Weakness
 Loss of function
 Post Trauma
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34. Subjective Assessment
 Pain
 Use Body Chart
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35. Subjective Assessment
 Area of current symptom:
 Where exactly your pain is?
 P1 vs P2 – relate them
 Relationship of symptoms
 Check relevant areas
 Intensity of pain
 Quality of pain i.e. sharp, dull, burning, tingling, excruciating
 Radiating or Non radiating
 Deep or Superficial
 Abnormal sensation:
 paraesthesia, analgesia, neurogenic (central,peripheral)
 Constant or Intermittent
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36. Constant or Intermittent
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37. Subjective Assessment
 Special question
 Spine
 P&N
 Numbness
 Headaches – rule out Migraine
 VBI signs
 Cord signs
 CE signs
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38. Subjective Assessment
 Shoulder
 Dislocate, Clicking,
 Knee
 Grinding, Buckling, Locking
 Ankle
 Give way
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39. Subjective Assessment
 Is the Disorder Irritable?
 Provoking activity and Severity
 Degree and quality of increased symptoms
 How long it takes to increase and ease
 Aggravating and Relieving factors
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40. Subjective Assessment
 24/24
 Am : inflamation vs degeneration
 Pm : mechanical stress vs degenerative process
 Night :
 difficulty going to sleep
 Comfortable and uncomfortable position of sleep
 Does movement or position wake him up
 How many times does he wake up in night
 What type of pillow and mattress is used
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41. Subjective Assessment
 onset
 How long have you had it?
 Sudden
 Incident – Stuck (mechanism/ swelling), Not stuck
 No incident- wakened with, During am/ pm
 Gradual
 What did you notice first? – from predisposing activities
 Unusual, heavy, sustained posture, over tired, cold/ damp
 PMH-
 first bout in detail- cause, duration, treatment
 Successive bouts- frequency, ease of cause
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42. Current History/ Past Medical
History
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43. Activity!
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44. SOAP
Subjective: how patient feels/thinks about him. How
does he look. Includes PC and general
appearance/condition of patient
Objective – relevant points of patient complaints/vital
sings, physical examination/daily weight,fluid
balance,diet/laboratory investigation and interpretation
Plan – about management, treatment, further
investigation, follow up and rehabilitation
Assessment – address each active problem after making
a problem list. Make differential diagnosis.
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45. Summery
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46. Social History: alcohol.
 Whether drinking alcohol or not.
 If drinking know whether it is healthy or not.
 Healthy alcohol use:
 Men: 14 units/week, not > 4 units/session.
 Women: 7 units/week, not > 2 units/session.
 Don’t forget that healthy alcohol use is associated
with less IHD & Ischemic CVA.
 Unhealthy alcohol use is associated with
cardiomyopathy, CVA, Myopathies, liver cirrhosis &
CPNS dysfunction.
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50.  ADLs (Activities of Daily Living) and IADLs (Instrumental Activities of Daily Living) are two
types of daily activities that are essential for independent living.
 # ADLs (Activities of Daily Living)
 - Basic self-care activities that are necessary for daily living
 - Examples:
 - Bathing/Showering
 - Dressing
 - Grooming
 - Toileting
 - Feeding/Eating
 - Transferring (e.g., from bed to chair)
 # IADLs (Instrumental Activities of Daily Living)
 - More complex activities that require cognitive and physical abilities
 - Examples:
 - Managing finances
 - Shopping for groceries or personal items
 - Preparing meals
 - Doing laundry
 - Managing medications
 - Using the telephone
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51.  Key differences:
 - ADLs focus on basic self-care, while IADLs focus
on more complex tasks that require cognitive and
physical abilities.
 - ADLs are typically more essential for daily
survival, while IADLs are important for
maintaining independence and quality of life.
 Healthcare professionals often assess ADLs and
IADLs to evaluate an individual's ability to live
independently and to identify areas where
assistance may be needed.
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53.  # Inappropriate Words
 - Words that are offensive, insensitive, or unacceptable in a particular context or culture
 - Examples:
 - Profanity or swear words
 - Racist or sexist slurs
 - Insults or derogatory terms
 - These words can be understood, but their use is considered impolite, hurtful, or
unprofessional.
 # Incomprehensible Words
 - Words that are difficult or impossible to understand due to their complexity,
ambiguity, or lack of clarity
 - Examples:
 - Technical jargon or specialized terminology
 - Words with multiple meanings or connotations
 - Words that are misspelled, mispronounced, or used incorrectly
 - These words can be confusing, even for people with strong language skills.
 Key differences:- Inappropriate words are clear in meaning but unacceptable in context.
 - Incomprehensible words are unclear or confusing, making it hard to understand their
intended meaning.
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54.  In the context of the Glasgow Coma Scale (GCS), abnormal flexion
and abnormal extension refer to two types of abnormal posturing:
 # Abnormal Flexion (Decorticate Posturing)
 - A patient exhibits flexion of the upper limbs (bending of the
arms) and extension of the lower limbs (straightening of the legs)
 - Indicates a severe brain injury, but with some preservation of
brainstem function
 - Score: 3 (out of 6) in the Motor component of the GCS
 # Abnormal Extension (Decerebrate Posturing)
 - A patient exhibits extension of both upper and lower limbs
(straightening of the arms and legs)
 - Indicates a more severe brain injury, with loss of brainstem
function
 - Score: 2 (out of 6) in the Motor component of the GCS
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55.  In summary:
 - Abnormal flexion (decorticate posturing) indicates
a severe brain injury, but with some preservation of
brainstem function.
 - Abnormal extension (decerebrate posturing)
indicates a more severe brain injury, with loss of
brainstem function.
 The GCS is a widely used system to assess the level
of consciousness in patients with brain injuries
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56. Feature Decorticate Posturing Decerebrate Posturing
Arm Position Flexed at elbows,
towards the body
Extended straight out
Leg Position Extended Extended
Significance Damage to corticospinal
tract
More severe brainstem
damage
(midbrain/upper pons)
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58.  These terms refer to the three main body types or somatotypes, as introduced by
American psychologist William H. Sheldon:
 *Ectomorph*
 - Characterized by a slender, lean, and delicate body build
 - Typically have:
 - Narrow bone structure
 - Small muscles
 - Fast metabolism
 - Difficulty gaining weight
 - Often described as "thin" or "lean"
 *Mesomorph*
 - Characterized by a muscular, athletic, and well-proportioned body build
 - Typically have:
 - Wide bone structure
 - Large muscles
 - Medium metabolism
 - Easy to gain muscle mass
 - Often described as "muscular" or "athletic"
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59.  *Endomorph*
 - Characterized by a rounded, curvy, and soft body build
 - Typically have:
 - Wide bone structure
 - Large fat storage
 - Slow metabolism
 - Difficulty losing weight
 - Often described as "curvy" or "voluptuous"
 Keep in mind that:
 - These body types are not absolute and can vary across individuals.
 - Many people have a combination of characteristics from multiple
body types.
 - Body type is influenced by genetics, lifestyle, and environmental
factors.
 Sheldon's somatotype theory aimed to categorize individuals into
these three main body types, but it's essential to remember that
human bodies are diverse and complex.
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63. Name Location
1 Preauricular Anterior to the tragus of the ear.
2 Posterior auricular Along the mastoid process.
3 Occipital
Inferior to the occipital bone and on the lateral side of the
occipital bone.
4 Submental Under the chin behind the bony prominence.
5 Submandibular Halfway between the submental nodes and the angle of the jaw.
6 Tonsillar Inferior to the angle of the jaw.
7 Superficial cervical
chain
Along the sternomastoid muscle at the top, just below the
mastoid process.
8 Deep cervical chain Further down the sternomastoid muscle.
9 Posterior cervical
chain
Behind the sternomastoid muscle.
10 Supraclavicular Superior to the clavicles.
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67.  Prothrombin Time Test. A prothrombin time
(PT/INR) test measures how fast a blood sample
forms a clot. Healthcare providers often do this
test to monitor how fast your blood clots if
you're taking the blood thinner warfarin. It's
also used to diagnose blood disorders.
 PT; 11 to 13.5 seconds. · INR of 0.8 to 1.1. · INR
of 2.0 to 3.0 if you're taking warfarin.
 The normal bleeding time is between 2-7
minutes. The normal clotting time in a person is
between 8-15 minutes.
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