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