subjective examination · open-ended questions directed questions forced choices repetition of the...

Subjective

Examination

“ The patient is the most valuable source of

information and our ability to extract that

information will determine our depth of

understanding, and subsequently our

ability to manage the patient’s problem.”

“ However, the patient will not know what is not

important and cannot be expected to know

what we do, and do not need to know. This is

important as we need to be skilled in helping

patients through accounts of their problems and

virtually teach patients how to listen to their own

bodies and inform us of relevant information.”

-Jones and Butler 1991

Subjective Exam:

Purpose?

Establish an accurate and sensitive

baseline

Plan your objective exam

Subjective: Baseline Pathobiological Pain Mechanisms

Functional Limitation and/or disability

Source of Symptoms or Dysfunction

Contributing Factors

Precautions and Contraindications to

Physical Examination and Treatment

Management

Prognosis

Subjective:

Planning your objective

Limited vs. Full Examination

Severity

Irritability

Progression

Stability

Pathology

Behavior

Communication

Nonverbal communication

Spontaneous information

Use patient’s words

Active listener

Never assume anything

Assume responsibility

Communication

Open-ended questions

Directed questions

Forced choices

Repetition of the story

Subjective Exam:

Getting Started

Get to KNOW your patient

WHY is this important? WHY first?

WHY is this different than the paperwork?!

Occupation: details Limited?Painful?modified?

Household Limited?Painful?modified?

EXERCISE, hobbies, interest Limited?Painful?modified?

Subjective: Components

Establish ‘kind’ of disorder

Site/ Area of symptoms

Behavior of symptoms

Special questions/ med history

Present episode

Related past history

Body Chart!

Identify all structures in each location of pain that could be “possible” sources of pain

Remember….

somatic (local)

referred

peripheral

vascular

visceral

Body Chart Example

Body Chart Example

P1

Contractile Multifidus, QL, Erector Spinaoe, Longissimus,

Gluteals, Psoas, Lats, Transversus

Non-contractile Vertebrae, ilium, sacrum

Joint: facet, Transverse/ Spinous process, SI

SI ligaments, TLF, capsule, ISL, SSL

Somatic Referred Hip, disk, contralateral facet

Nervous Sciatic Nerve, Nerve Root- above, below

Visceral Kidney, Gall Bladder, Appendix

Body Chart Example P2

Contractile Gastroc, soleus, politeus, peroneals, posterior tib

Non-Contractile Tibia, fibula Joint: Proximal Tib-Fib, Knee, Patella-Fem

Nervous: Sciatic, Peroneal, Sural, Tibial, Nerve Root

Both-relationship established? Disc, nerve root, facet

Behavior of Symptoms

Aggravating factors

Measurable (time)

Easing factors

Linger?

Pain Medication

Day Pattern

AM, Day progression, Sleep (GTS, Wake)

Relevant Past Medical History

Review Chart

Do meds make sense??

Surgical History

Abdominal Surgeries for LBP

Urine Leakage LBP

Special Questions should be reviewed

relevant to UQ or LQ

Fall Screens

Present Onset/ Past Episodes

Why last?

Treatment

Progression

Diagnostics

Prior Treatment

Subjective: upon completion

Mechanical vs chemical

“Kind of disorder”

Body region primarily to be examined

Body regions to be cleared

Neurological exam

Degree of provocation

Severity, irritability, nature, stage, stability

Hypothesis

Communication:

Self Assessment

Clear and Concise?

Non-verbal behaviors interacting?

Rapport established?

Effectively perceiving, interpreting?

Spontaneous information?

Using patient’s words?

Assumptions?

Open ended questions?

Relevant observation?

Communication:

Self Assessment

Collaboration

Patient’s initial concept of problem?

Drawing information from patient’s frame of reference?

Learning promoted?

Explanations?

Self management?

Negotiation?

Goals?