Subjective Assessment Flashcards
What is a subjective assessment?
- Initial assessment where we talk to our patients and gather information
- Discussions with other clinicians, family or carers
- Reading referrals or notes to gather initial information
What are the aims of your subjective assessment?
- Build rapport with your patient
- Gather information (to plan our objective assessment)
- Establish differential diagnoses
- Establish the main problems and patient’s goals / expectations.
- Evaluate patient awareness, knowledge and insight.
- Establish baseline subjective markers
What areas of subjective assessment should be included in MSK?
- History of present condition (HPC)
- Past medical history (PMH)
- Drug history (DH)
- Social history (SH)
- Patient goals / aims / expectations
- Differential diagnoses
What can interpersonal skills in a subjective assessment significantly contribute to?
- Patient and healthcare provider satisfaction
- Problem detection and diagnostic accuracy
- Patient adjustment to stress and illness,
- Patient recall of information and adherence to therapy plans
- Patient health outcomes
What percentage of clinicians can obtain their diagnostic info in a good subjective history?
60-80%
What percentage of subjective histories can lead to a final diagnosis?
70%
What are some expectations the patient may have from their assessment?
- Diagnosis
- Advice
- Exercises to help manage pain
- Reassurance
- Cure or resolution of their pain
- Reduction in their ain so they can self-manage
What is discovered during the History of Present Condition (HPC) section of a subjective assessment?
- Current symptoms
- Timeline
- Pattern of symptoms
- Treatment/investigations
- Mechanism of injury vs insidious onset
What is discovered during the Past Medical History (PMH) section of a subjective assessment?
- Previous operations, accidents or significant illnesses (THREADS)
- Relevant current medical conditions
- Specific ‘red flag conditions’
What is discovered during the Drug History (DH) section of a subjective assessment?
- Current medication (anticoagulation?, analgesics?)
- Significant past medication
- Specific ‘red flag’ medication
What is discovered during the Social Health (SH) section of a subjective assessment?
- Occupation
- Relevant social or family situations
- Hobbies & interests
How can we record signs & symptoms (S&S) in a clear, detailed and succinct way?
Body Chart
What are some symptoms that mean extra caution is needed?
- Excessive symptoms
- Neurological symptoms (P&N / numbness)
- Symptoms of instability
- Symptoms not matching MOI / problem
What are examples of signs & symptoms (S&S)?
- Pain
- Pins and needles
- Giving way
- Locking
- Stiffness
- Swelling
- Bruising
- Numbness
- Instability
- Clicking/popping/clunking
What questions would you ask about pain location?
- Exactly where is the pain?
- Can they point with one finger or is it the whole hand?
- Where does it start, where does it refer to?
- If there are more than one pain locations are they related?
- Is it deep or superficial (near the surface)?
- Do they come together or separately?
What information might we want to get about a patient’s pain?
- Severity
- Duration (when it started, how long each episode lasts, constant?)
What are non-verbal pain cues?
- Facial expression (grimace, redness/pale, clench teeth, shut eyes)
- Body language (deep breathing, withdraw from touch)
What are examples of words used to describe pain?
- Aching
- Throbbing
- Burning
- Shooting
- Prickling
- Lancing
- Stinging
What does night pain suggest in an assessment?
More severe pathologies
What does 24-hour pain pattern show in an assessment?
- Aids diagnosis
- AM pain + stiffness (indicate inflammatory)
What are (4) pain cautions to look out for?
- Non-mechanical pain: No clear aggravating factors or easing factors
- Unrelenting pain
- No 24-hour pattern: pain through the day and night
- Night pain: severe pain which prevents or wakes from sleep (Manageable night pain is not uncommon)
What do easing factors for pain show in an assessment?
Aids diagnosis
What do aggravating factors for pain show in an assessment?
- Aids diagnosis
- Provides objective markers
What are ‘red flag’ questions?
Questions that indicate more serious pathology
- Cauda equina symptoms
- PMH THREADS questions
What is SIN (pain)?
- Severity (low/moderate/high or VAS)
- Irritability (low/moderate/high)
- Nature (nociceptive (mechanical/inflammatory)/Neuropathic or peripheral neurogenic/central sensitisation))
- OR the origin of the pain
What is irritability (pain)?
A disorder’s susceptibility to become painful, how painful it becomes and the length of time this pain takes to subside.
(low/moderate/high)
What is nociceptive pain?
- Pain derived from tissues by mechanical or chemical processes.
- Most likely to be associated with an acute injury, with damaged and healing tissues and postural pain.
What is neuropathic/peripheral neurogenic pain?
- Pain derived from the nerve itself or its connective tissue by mechanical or chemical stimulation.
- Has characteristic qualities typical of nerve irritation and involvement including the sensation and behaviour of the pain
What is nociplastic pain/central sensitisation?
- Derived from a hyperactive and hypersensitised nervous system (where the stimulus would not normally trigger a pain response and can be strongly linked to stress and emotion).
- Can be a feedforward response where thoughts and feelings can elicit a pain response.
What questions do you need to ask your patient in relation to Cauda Equina Syndrome (CES)?
- Do you have pain down both legs (sciatica)?
- Have you noticed any changes in your bowel, bladder or sexual function?
- Do you have difficulty controlling your bowel or bladder?
- Can you feel your saddle area when you wipe?
- Have you noticed any disturbances in your walking?
What are some key questions to ask patients (in relation to suspected/diagnosed cancer)?
- Over 50 years old
- Unexplained weight loss (> 5% over 6 months).
- Constant severe unremitting pain
- Night pain that prevents or disturbs sleep
- Thoracic pain
- Previous history of cancer
