Components of the Subjective Exam Flashcards
Where does the Subjective Exam fall?
Evaluation and Examination
What is the Primary Objective of the Initial PT visit?
Phase 1 differential Diagnosis- Does this patient belong in my clinic?
What is the Steps in the Subjective Exam Flow?
- Review Baseline Information/ Chart Review
- Establish Rapport
- Gather General Information
- Analyze information/ Hypothesis Generation
- Gather Specific Information
- Plan objective Exam
____% of the information needed to determine to make a diagnosis is contained in the subjective exam.
80%
Step 1: Review Baseline Information/Chart Review
Provides needed information:
- General Health Status
- Imaging Findings
- Operative reports
- Past Medical History and/or treatments
- Medications
Step 2: Establishing Rapport
- Welcoming Introduction
- Establish effective communication and rapport
- Explanation of perspective
- clarification of patient expectations
- Sequence of first session- exam process and patient’s role
Step 3: Gather General Information
- Patient profile
- Chief Complaint
- Body Chart
- Present Episode
- Past History
- Aggravating/ Easing Factors
- Relationship between regions
- 24 hours behavior
- Patient goals
- Patient Expectations
Body Chart- Problem Area Characteristics
Location- of each area of pain/ symptoms quality- type of symptoms depth- of symptoms frequency- constancy of symptoms Relationships- between areas of symptoms clearing- relevant areas
Body Chart- Rating pain
Numerical Pain Rating Scale (NPRS)- on a scale of 0 to 10…
Visual Analog Scale (VAS) for pain
Radicular Symptoms
direct stimulation of a nerve root results in a sharp, lancinating pain, well-localized to the dermatome.
Visceral Referral
Kidney, pancreas, cardia etc. can mimic or masquerade as musculoskeletal pain
Somatic referral
symptoms that arise from referral of a musculoskeletal structure (i.e. facet jt.)
Trigger Point
hypersensitive spot typically in skeletal muscle that can be associated with a taut band
Step 4: Analyze Information/ Hypothesis Generation
Hypothesis generation–> Hypothesis Refinement–> Primary Hypothesis
Step 5: Gather Specific Information
Date of onset?
Mode of onset? (Gradual or sudden onset)
Immediate or delayed symptoms after injury? (Pain and Swelling)
Are symptoms getting better, worse, or status quo?
Any treatment to date? Effects?
24- Hour Behavior
