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2016

TheImportanceoftheSubjectiveExamination

TheImportanceoftheSubjectiveExamination
Thesubjectiveexaminationisoftenundervaluedintheassessmentandmanagementofapatient.Itisthe
mostcrucialaspectoftheexaminationasitdeterminestheseverity,irritabilityandnature(SIN)ofthe
patientscondition.Goodquestioningleadstotheformationofprimaryandsecondaryhypotheses,possible
methodsoftreatmentandlikelyprognosisoftheinjury.Recently,Iassessedanactive30yearoldfemale
withleftanklepain.Herbodychartsuggestedatibialisposteriortendinopathy,withapreviousleft
evertortendinopathyandleftgastrocnemiustear.Onquestioningaboutmedications,thepatientstatedshe
wastakingAmpyra,acommonmedicationusedtoimprovewalkingspeedinthosewithmultiplesclerosis.
Thiscompletelyalteredtherestofmyquestioningandphysicalassessment.Thissimplequestion,often
forgottenorundervalued,drasticallychangedmydiagnosisandprognosisinthiscase.Thefollowing
structureallowsquicktransitionbetweensectionsofthesubjectiveexamination.Byfollowingthisroutine,
youshouldhaveasolidunderstandingofthepatientsconditionandreducetheriskofmissingasinister
pathology.BodyChartAreaofsymptomsmustdetermineeachaspectofsymptomsforeacharea
Locationanddistribution
Symptomspain,pins&needles,numbness
Typeofpainache,burning,throbbingetc
Constantorintermittent
Intensity
Relationshipofeachsymptomorarea
Usedtodeterminediagnosisandprioritisingoftreatment
NecessaryindeterminingdiagnosisandmonitoringasterisksignsAggravatingFactorsEssentialin
determiningirritability(aconceptdescribedbyGeoffMaitland,thedegreetowhichaninjuryisexacerbated
bycertainactivities)
Aggravatingactivitytimetoonset,intensityofsymptoms,timetoeaseonceasingactivity
EasingFactorsUsefulintreatmentselection24HourBehaviourValuableindetermininganinflammatory
condition
AMintensityofsymptoms,timetoease
Daybehaviourduringdaye.g.dependsonactivity,worsebyendofday,betterasdaygoeson
PMpainful/comfortablepositions,timetogettosleep,wakeinnight,timetoreturntosleep
SpecialQuestions
Nightsweats
Malaisefeelingofgeneraldiscomfort,uneasiness,beingoutofsorts
5Ds(Cx)dizziness,dysarthria(speech),dysphagia(swallow),diplopia(vision),dropattacks,assistsin
determiningriskofvertebralarteryinvolvement
Cordsignsgloveandstockingparaesthesia,balanceproblems
Caudaequinasignsbowelorbladderchanges(urinaryretention,unabletocontrolanalsphincter)
Medicationsforpainrelief,forotherconditions
GeneralHealthdoyouhaveanyothermedicalconditions?howisyourgeneralhealth?
Investigationshaveyouhadorbeenreferredforanyscans?

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CurrentHistory
Onsetandmechanismofinjury
Behaviour/progressionofsymptomssinceonset
Treatmentsinceonset
PastHistory
Previousoccurrenceswhen,mechanism,previoustreatment&response,recoverytime
Previousinjuriesrelatedtopresentingconditione.g.3/12postankleinjury,presentingwithanterior
kneepain
SocialHistoryAssistsinreturntoworkandreturntosportrehabilitation,determinesgoalsoftreatment
Employmentnatureofwork,hoursperweek,effectofinjuryonworkstatus
Livingsituationdependents,homeduties,stairs,activitiesofdailyliving
Recreationlevelofactivity,sessionsperweek,guidesrehabilitation
GoalsOftenforgotten,itscrucialtoknowthepatientsexpectations.Youmaybeoverestimatingor
underestimatingtheirdesiredlevelofactivity.Italsohelpswithunderstandingthepatientsperspectiveon
theirinjuryandgivinginsightintosomecognitivefactors.QuestionnairesQuestionnairescanbeusedto
providevaluableinformation.Withagrowingawarenessaboutchronicpainandbiopsychosocialmodelsof
pain,thesecanprovideinvaluableinformationoftenmissedinastandardassessment.Tips
TheOpeningQuestion...itmustbeshort,direct,andencouragethepatienttotellyoutheirissueandbe
thesamewitheverypatient.SomeexamplesareTellmeaboutyourproblemSo,whatstheproblem?
HowcanIhelpyou?WhatcanIdoforyou?
Completeyourbodychart,includingclearingotherareas,beforecontinuing.Itallowsacomprehensive
viewoftheinjury,preventingyougettinganastysurpriseofarmnumbnessduringyourcurrenthistory
questioning.
Followuponanswerswithfurtherquestioningiftheresconfusion...youwakeinthenight,isitpain
thatwakesyou?youreexperiencingblurredvision,doyouusuallywearglassesorhavevision
problems?
Whenaskingaboutmorningpain,askhowisyourpain/symptomsinthemorningcomparedtobefore
youwenttosleep?,thisnarrowstheinterviewtothepatternoftheircurrentpainratherthantheir10
yearhistoryofachingknees.
Generalhealth...oftenpeoplesayImfineorgoodwhenaskedaboutgeneralhealth.IntheAustralian
culturewehaveatendencytodownplayanyillnesses.Ifinditbesttoaskdoyouhaveanymedical
conditions...sonodiabetes,heartconditions,lungconditions,osteoporosisetc.
Wellcomebacktothat...theperfectwaytodirecttheinterviewwhereyouwantittogo,ifapatient
startsdiscussingtheirpast20yearsofmedicalhistorywhenyoustillhaventdeterminedtheirbodychart,
thislineisalifesaver.
AliciaReferencesMaitland,G.D.(1991).Peripheralmanipulation(3rded.).LondonBoston:Butterworth
Heinemann.O'Sullivan,P.(2012).It'stimeforchangewiththemanagementofnonspecificchroniclowback
pain.Britishjournalofsportsmedicine,46(4),224227.Refshauge,K.,&Gass,E.(Eds.).(2004).
MusculoskeletalPhysiotherapy:ClinicalScienceandEvidenceBasedPractice.Sydney:Butterworth
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Heinemann.

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